Why It Matters
Photo by CHUTTERSNAP | Unsplash
If you remember what critical care was like in the 1990s and through much of the early 2000s, you will recall the beliefs and attitudes many clinicians had about the serious problems — including delirium — that many patients experienced:
It’s ICU psychosis.
We know everybody’s going to get it.
What’s the problem?
Back then, it was not uncommon for people like Wes Ely, MD — and others advocating safer and more humane ways to handle delirium, sedation, and mobility in intensive care — to face doubt, confusion, or resistance from their colleagues. But, fortified with evidence, they proved that big changes were necessary to prevent patients from being irreparably harmed by the care meant to save their lives.
“We proved that delirium tripled the risk of death by six months,” recalls Ely, a professor of medicine at Vanderbilt University School of Medicine and co-director of the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt University Medical Center and the Nashville VA. “Every additional day of delirium increases the risk of death by 10 percent.”
Through the Institute for Healthcare Improvement (IHI) Rethinking Critical Care seminars held between 2011 and 2016, Ely and other faculty members (including Intermountain's Terry Clemmer, Vicki Spuhler, and Polly Bailey, and IHI’s Kelly McCutcheon Adams) taught clinicians how to reduce harm to critically ill patients by decreasing sedation, increasing monitoring and management of delirium, and increasing patient mobility. In the following interview, as IHI celebrates our 30th anniversary, Ely reflects on this groundbreaking work and how COVID-19 has threatened to undo it.
On the care that was once typical for an ICU patient on a ventilator
I trained in critical care in the mid- to late-1990s. It was usual care to keep every patient sedated and paralyzed through the 90s and into the early 2000s. Around 2004 or 2005, we began developing the ABC — Awakening, Breathing, Control — approach, and coordinated between respiratory therapists and nurses to lessen sedatives to have patients more awake. But even up until 2010, it was still commonplace to have people very deeply sedated and immobilized for five, ten, and sometimes 15 days or more. In the United States, it was IHI, through a series of collaboratives and meetings across the country, that started the sea change toward the approach that we now call the A to F bundle or the ABCDEF bundle in critical care.
On the patient who helped inspire the leaders of critical care transformation
Joy Sundloff was a patient of Terry Clemmer’s, Vicky Spuhler’s, and Polly Bailey’s at Intermountain Healthcare in Salt Lake City [in 1994] when ICU patients were deeply sedated and immobilized. She had acute respiratory distress syndrome (ARDS) from bacterial sepsis, and it ruined her life. The massive cognitive impairment and physical disabilities she experienced after she got out of the ICU [after five months] were created by the ICU, not by her original illness. The nurses, doctors, physical therapists, respiratory therapists, and others around the world who heard her story — and had seen people like Joy in their own hospitals — started saying to themselves, “We don’t mean to, but we’re hurting people. This is a public health problem. Something has to change.” Joy eventually got her life back, but only after years of cognitive and physical rehabilitation.
On Wes Ely’s patient who compelled him to change his practice
I had a patient named Teresa Martin. She was a young woman in her late twenties. I thought I was doing my best for her. After she survived, against the odds, I expected this great reunion with her when she walked in to see me in clinic. I had imagined she’d say, “Thanks for saving my life. I’m back at work and everything is great.” Instead, her mother wheeled her in, and Teresa was in kind of a haze, unable to walk months after being in the ICU. Her mother looked at me and said, “What’s wrong with Teresa? Why is my daughter now a totally different person than she was before?” I felt an immense amount of shame, and embarrassment, and confusion in my heart and in my mind when I had those early patients with post intensive care syndrome (PICS) before we even knew that was what it was called.
On how people reacted to the recommendation to mobilize intensive care patients
We got a range of responses. Some people reacted with disbelief: You are crazy. We can’t have people awake on a ventilator. There’s no way you can walk somebody on a ventilator. That’s completely unsafe. That’s going to kill them. Some people understood: I know my patients are acquiring disease in the ICU. My patients are definitely acquiring muscle and nerve disease. When I see them back in the clinic, they haven’t been able to go back to work.
On how things started to change
Early adopters and the people who were ready to change tended to put down the late adopters, but Kelly [McCutcheon Adams] and the IHI taught us that late adopters have institutional memory, and they remember when we tried something before that didn’t work. That makes them just as important as the people who are ready for change. We started to make progress once we started breaking down the barriers, listening to one another, and generating data. People wanted proof. So, we started doing the ABC trial, which was published in Lancet. We conducted another study, which we published in JAMA, in which we proved that sedatives other than [benzodiazepines] resulted in less delirium and coma. Once we put all these studies together — involving thousands of patients over about a decade — we created an effective safety bundle to help protect patients from iatrogenic harm as they went through critical illness. We started proving, one study at a time, that there was an alternative approach to critical care that was safer and allowed people to survive with fewer cognitive and physical impairments.
On how rethinking critical care means rehumanizing it
When some people learned about the risks of delirium, the first thing they wanted was a drug to treat it. Drugs didn’t turn out to be the answer. We did that for 50 years, treating delirium with Haldol and other anti-psychotics, and we don’t do that anymore. We’ve now proven in a paper we published in the New England Journal of Medicine called the MIND-USA Study, that anti-psychotics do not treat delirium. We can still give anti-psychotics to help calm the patient and because they don’t suppress the respiratory drive, but we don’t give them to treat delirium.
The environmental part of [treating and preventing] delirium is one of the most important ways IHI influenced how we do critical care now. IHI realized that [helping patients have access to] things like eyeglasses and hearing aids, and turning the lights on, and all the things that help reorient patients also help to rehumanize them. It’s about preserving human dignity.
I love that the Institute for Healthcare Improvement taught us how to elevate the human condition and rehumanize care through the Rethinking Critical Care program. It’s a great example of how quality improvement can redirect our attention to what really matters. We handed off the work we started with Rethinking Critical Care to the Society of Critical Care Medicine at which time there was a large ICU Liberation program. We ended up studying 15,000 people in the ICU Liberation program. And that was on top of another 6,000 people in an earlier program. [By studying] over 20,000 patients, we proved that this worked. We had absolute lockdown proof that the ABCDEF bundle reduces death, reduces length of stay, reduces delirium and coma, reduces bounce backs to the ICU, and even reduces nursing home transfers.
On how COVID-19 has threatened progress on transforming critical care
So, we’re ticking along and [between] about 2015 to 2018, we started getting our best percentages of compliance with the ABCDEF bundle. For the first time in 20 years of measuring delirium in large multi-center trials and large multi-center cohort studies, we started getting very consistent numbers in very sick ICU patients of delirium rates in the 40 to 45 percent range. It had always been 75 to 80 percent.
Then COVID hit, and we essentially lost those 20 years of progress. Suddenly, we had 80 percent delirium again. We had people in prolonged comas. We had benzos rampantly being used across the ICU world where they’d almost been eliminated. It was really sad. I know we were trying our best. We were scared of the virus, and we didn’t have enough PPE at the beginning. But I will tell you that there were times when I was standing in the unit on rounds with the COVID patients and thinking, “I’m in the 1990s again. How did I go back in time?” because what I was seeing was antiquated care.
On why he is optimistic about the future of critical care
We’re absolutely making progress. There is a stalwart approach right now to get our feet under us and get back to the bundle approach of wake up and breathe every single day, liberate patients from sedation, wake them up, and get them moving. Now, not every patient can do that. But for every patient, we have to consider every day whether we can safely stop their sedation. Let’s try to wake them up and get them out of the bed.
We trained about four or five great fellows here in the last decade. They’re all down in Louisiana now in Baton Rouge and New Orleans. They called me and they said, “Wes, early in the pandemic, we were scared, and we lost our way. We’re finding our way again. We’re doing what we know works. We’re using a data-driven approach, and we’re going to treat these people the way we know they can be treated.”
I got a picture two weeks ago from a woman who was in the hospital in Baton Rouge. She was getting the full A to F Bundle. She had COVID and they took a picture of her holding up a note she scribbled on a board that said, excuse my French, “Get the damn vax.” She was a woman with COVID on 100 percent oxygen who was intubated on a PEEP of 18 with a tube down her throat, wide awake, writing a note to her family to tell them to get vaccinated. And that’s what the bundle is all about. It’s about treating people with dignity and respect.
Editor’s note: This interview has been edited for length and clarity. See photos of some of the people mentioned in this interview. Dr. Ely is donating the net proceeds from his book, Every Deep-Drawn Breath, to a fund at the CIBS Center established to help ICU survivors and their families. You can find him @WesElyMD.