Okay, we're going to get started. Welcome, everyone, to TCA's webinar today. We're very happy to have Dr. Melody Campbell with us, and she's going to be talking about ICU for the best practices for the trauma patient caring for the critically injured. And so, I'm just going to briefly introduce her. Dr. Melody Campbell is the Trauma Program Manager Clinical Nurse Specialist at Kettering Medical Center. Dr. Campbell earned a BSN and MSN with a concentration in burn and trauma nursing from the University of Cincinnati. She has published in Critical Care, Emergency and Trauma Texts, including the Trauma Nursing Core Course, Emergency Nursing Core Curriculum, and is a reviewer for the Journal of Trauma Nursing. Dr. Campbell obtained her DNP from Wright State University with a dissertation focused on early mobility in the ventilated patient. So, thank you, and welcome, Dr. Campbell. Thanks for being with us to present this webinar for us today. Thank you so much, Christine. And thank you so much to Deb Myers for asking me to present. Her and I have known each other for a few years, perhaps more than we would like to say, and go back to a time when Ohio was very purposefully and aggressively working on its trauma system across the state, and her and I both were Trauma Program Managers of Level 3 trauma centers at that time. So, thanks, Deb. I appreciate it so much. And I appreciate all of you being on. I do encourage you, if you have a question, to put it in the question and answer box. I do have that pulled up, and we'll try to take questions as we go. I want to first say that I don't have any disclosures, and we talked a little bit, Christine and I, about Zoom and about how used to these online platforms were getting to be. And I was telling her a story about my mom, and it's just a funny story to begin with. The first time we had a Zoom dinner that she was actually sweeping her whole house, and she put her makeup on and her perfume, getting ready for our Zoom dinner because she said the kids are coming. And you have that approach to being on Zoom and the opposite approach of still people wearing their pajamas and not getting on camera. So, it's a unique platform for us to use, but so very helpful. So, I don't have any disclosures, and you see the gentleman on the screen has the pockets empty. And all of these schools that are represented are schools where my children have gone, and my pockets are empty because my money has gone there. And in your household, you're not supposed to have children that go to sparring institutions. However, my situation, my family, my kids have done that. And so, my oldest is a sousaphone player that went to The Ohio State University and part of the marching band and dotted the I. And then my youngest went to the University of Michigan. And so, always around Thanksgiving, it gets to be a challenging time in our household and when those two schools play each other. This year, perhaps not so much. But knowing that about me, if you see me somewhere, you can talk to me about that in our family. How's that little difficulty going? So, our first polling question is just to get you started interacting and what is your degree? If so, you'll fill that out, then Christine will let us know what the results are. Okay let's see what we've got. Awesome so we have 64 that are nurses, registered nurses for APPs, four physicians, and two others. So welcome to our program this afternoon. And then we'll go to the next slide. So where we started off with this is really thinking about airway breathing circulation disability in ATLS and moving past that resuscitation time with our patient into the care of the patient in the intensive care unit. And thinking about a different bundle. And I hope this will be review for you. I've tried to pull some things from that bundle that are unique to trauma and unique to the complications that we try to prevent. And so we'll talk about that that bundle. A stands for assess, prevent, and manage pain. B is both spontaneous awakening trials and spontaneous breathing trials. C choice of sedation. D stands for delirium. We're going to assess, prevent, and manage that. E is early mobility and exercise. And F family engagement and empowerment. So our polling question 2 is what's your familiarity with the ABCDEF bundle? I thought that choice, I choose not to be familiar with it, it was a good one. You like that, you like that. Yeah, just give it another, a few seconds here. OK, let's see. There we go. I have a working knowledge of it, 60%. I know where the policy is, 4%. I imagine these questions, you can only answer one of them and not more than one. I hear about it in team meetings, 18%. And then 19% said unsure, so that's great. All right, Christine, thank you. You're welcome. All right, so how are we doing with the bundle? And that's really what we need to focus on because one of the things that we know is that the bundle's been studied, the implementation's been studied in many hospitals and published. And it is, since it has so many parts, it is something that's difficult to integrate into your institution and then a little bit tough to sustain. And so it's something that we have to work on all the time, especially we have new people that start, new nurses, new advanced practice providers, residents, physicians. And so we're constantly thinking about, as well as our other folks, respiratory therapists, PT, OT and speech, can we have everybody speak in the same language, walking the same walk and talking the same talk so that we provide the care that we want with our patient? And so as all of us really being involved in coordinating, managing trauma programs and improving the care of our patients, we really have to have a hands-on approach and daily observation of the care that's happening. And we have a monthly meeting with our ICU team. First part of that bundle is analgesia first. It cannot be said too often that we really have to focus, and especially with our trauma patients, because they all have something that's broken most of the time, whether that's broken ribs, broken femurs, broken pelvises, you name it. They have real reasons for acute pain and reasons to treat. We know also that from looking at medical, surgical ICU patients, that patients have general pain at rest with standard procedures like turning and then with those invasive procedures that we do, such as insertion of arterial lines, central lines, chest tubes, and that the most pain in different studies were described with arterial catheter insertion, chest tube removal, turning, repositioning and suctioning. So when we talk about pain and managing pain in our ICU patients, we really have to make sure that we're using the right tools. And this is where it starts to be important for us to ensure that we're training our new folks and getting them used to using the right tools because we have specific tools in ICU that we should be using. So we're going to talk a little bit about those tools. So pain assessment, we know that the patient's self-report is the gold standard. And so if we can have them tell us exactly what they're sensing or how they feel and how severe that pain is, that's really the best thing. And so that numeric rating scale is the most valid tool when the patient can self-report. I think that we're learning how to keep our patients lighter when they're on the ventilator and still having that communication be able to take place so that the patient can still tell us how much pain they have by indicating with how many fingers they are or by pointing to a visual analog scale. So what pain assessment do you use most frequently in your ventilated patients? Christine will be tallying that for us. She's got some kind of map behind the screen. Here we go. Awesome. So some of you, 16% are using the behavioral pain scale, 65% using the CPOT, and the rest of you are using the pain scale. Awesome. So some of you, 16% are using the behavioral pain scale, 65% using the CPOT, some using Wong-Baker faces, and then 1% using pain add. So that's really interesting, and we'll talk about those. All right. So we know that there's two scales that are really recommended by those guidelines that have come out from the Society of Critical Care Medicine. And so the first set of guidelines, pain, agitation, and delirium, came out in 2013. And then that evidence was updated in the form of very particular questions in 2018 with the PADIs guidelines. And so they really advocated the use of the behavioral pain scale and the critical care pain observation tool. When we think about these tools, I think it's really important for folks to understand the difference between the patient's verbal report or the numeric rating scale and these two scales. When the patient reports their own pain, it's their own sensation of that pain and the severity of that. These two tools, the behavioral pain scale and the CPOT, are both our observations of the patient's behavior. So it's our scoring of their pain. And both these tools tell us only absence or presence of pain. It's not really how severe it is, it's absence or presence. And so these two tools are recommended because they have the greatest validity and reliability for monitoring pain in the ICU patient population. But the studies done in brain-injured patients are small. They have small ends. And so we have to continue to watch the literature for additional studies to be done. And just a reminder that the behaviors must be observable. And so for your patient to have a low GCS, like a GCS of 3, that is patient is unresponsive, they're not moving, they're not responding to anything, these tools cannot be used. Patients that have spinal cord injury, tetraplegia, it's high spinal cord injury that cannot move, we cannot use the tool. And then patients that have been paralyzed, obviously chemically paralyzed, then the tools cannot be used. And so we have to use other cues when we're assessing pain. Vital signs, we have to use family and those pieces. But I think it's really important when you think about our trauma patients that these are considerations that are important for our population. That's an image of the behavioral pain score scale. It does go from 3 to 12. Remember that you get presence or absence of pain. And it is a presence of pain if the score is greater than 5. Okay, so totally different idea than our 0 to 10 scale that we're really used to. So it's important to get our new folks really geared into understanding what the differences are so they can articulate it and talk with each other. Here's the CPOT. And the CPOT, as you can see, relies on facial expression, body movements, muscle tension, compliance with the ventilator, and then has an element for those patients that are not intubated. And it scores 0 to 8, and greater than 2 indicates presence of pain. I saw that a lot of you are using CPOT, and that's what I have used both here and the last place that I worked we used CPOT as well. So it's the one I'm most familiar with as well. One of the things that it's interesting, I'm married to a lawyer, and so I'm always looking for statements that look lawyer-like to me. And in the things that you read by Dr. Selene Gelinas, and she is the author of this tool, the person that studied it. And if the measurement of CPOT after an intervention for pain decreases by at least 2, this change in score may be associated with effectiveness of pain management interventions. And so if you've given some pain medicine to a patient and your score changes by 2, you can associate that with the effectiveness of pain management. It does sound very lawyer-like. But look for more studies to be done with these tools, more things to come out about them, because I think we're still in the early phases of learning about them still, especially in our brain-injured patient population. So there's always new folks on our team. Think about in your institution, how do you train new people? And I've said that a couple times now, so that everybody speaks the same language. Do you have health streams? That's something that we use that you can put a PowerPoint on and people can read it. Then how do you teach them when they're actually in the patient care environment? How do you talk about it in rounds? All those things so that you sustain the practice. All right. A little bit about pain management. We're not going to talk about specific drugs at all, but just thoughts to think about is that we want to be preemptive with our pain management, and we want to be carefully balanced with that pain control. And so preemptive means that we're thinking about pain medication prior to doing those painful procedures, making sure that we're medicating the patient, we're positioning the patient in a comfortable position if we can, and then continuing to reassess and provide more pain medication during that procedure, and then watching very carefully to make sure that we're balancing the right amount of opioid. Can we use other medications in a multimodal approach that are in other classes, so that we're trying to limit or decrease the amount of opioids if we can? Home medication reconciliation. I can't say enough about that because it's so important, and we spend time every day looking at what the patient was on before they came to the hospital because it really does help the patient progress. As the patient gets better and we can start some of those home meds, it really helps with our weaning of the ventilator, tolerating CPAP, those kind of things. We have to watch as well for things that we may not know about, that we have to be detectives to find out, and that's addiction and then alcohol use at home. And so we screen everybody for drugs, and you're in drug screening, we do alcohol screening. And then are watching some of their chemical profiles, looking for evidence of addiction and abuse. I worked seven years with the pharmacist every day next to me, so I'm very kind of tuned in, I think, sometimes with home med rec and some of the things that pharmacists would talk about every day because of her influence on my practice. We've used multimodal analgesia, all of us, in our institutions for a long time. We looked very carefully at the reasons for our unplanned admissions to the ICU and unplanned intubation and really honed in on our geriatric patient population. Our rib fracture pathway has multiple drugs on it, but some of our older folks don't tolerate having all of those started at once. And so we really talk a lot with our advanced practice providers, especially those that are new prescribers, about starting low and going slow, watching the patient carefully to see their response. We also talk to nurses on our floors about administering things at the same time and trying not to do that. And so we go with that very, very carefully, watch that combination of the opioid and a CNS depressant. So we might use Robaxin, we use Gabapentin or Neurontin, and so we watch those very closely, especially on that evening after surgery, that day after surgery, so that we don't get that additive CNS depressant. You need a good history, you need to look at their ORs to find out what their prescriptions have been in the past, and then check in with family, especially if you have changes in cognition. It's very important to get a good baseline with that patient and find out where they've been. And good communication between the prescriber and the nurse that's administering the drug. We use this scale, it's called the Pacero Opioid Induced Sedation Score, and we use it more on the floor. It is an assessment to look at sedation that's caused by the opioid to make sure that it's not too sedating. And so we have the nurses do that, they do it approximately an hour after the medication's been given, if it's an oral med, 30 minutes after an IV medication, and then they make a judgment about whether the dosage is right for the patient. We use this in our communication when nurses are talking to prescribers about changing pain medications to look at what the POS has been to make sure that our dose isn't already too sedating. That's been part of our practice to avoid that unplanned admission to the ICU and those unplanned intubations. Hope I said that right. So I'm sure you have guidelines for pain management. I should have made a polling question about that. And do you have a multimodal approach, and have you studied it? We're currently studying a couple of ours, and so we're looking at our hip fracture patients. We take care of those on our service. I'm not sure how many more patients can fall in our area and break their hips because it seems like we've seen one patient for this hip, and then several months later we'll see them for the next hip. We're not doing as well with our injury prevention program, but we do study the amount of opioid that we're giving to our patients that have pain balls with our hip fractures, and so trying to make sure that we are decreasing the amount of morphine equivalents that we're using for our patients by doing that multimodal approach. All right. This is one of the things that we looked at, and just to orient you to the slide, this is our INO flow sheet, and it's a place for you to check about the amount of drug that the patient is getting. And I look at this pretty often because it's a different view. We get used to continuous infusions of opioids being, for example, fentanyl, 25 mics per hour, and we don't think that's a lot. But in our elderly folks, when you count that up over 24 hours, it can add up very quickly to quite a bit of medication. And so in this patient, you can see in their INO the volume that they received in this 24-hour period was 432 milliliters of fentanyl. That's 4,320 micrograms of fentanyl in a 24-hour period. This was an 84-year-old lady. And so we used this to change some of our protocols. And so we actually have a panel, an order panel that we changed that is a fentanyl order panel that we start off with IV pushes first. Patient will get four if they need it before a continuous infusion is started, and then they get four more before the continuous infusion can be titrated up. This has helped us keep our total amount of drug in a 24-hour period down, and we have studied it. We need to study it again because as your staffing changes and you get new folks, it's important to make sure that your practice is staying the same, your orientation is good, and you're getting the same effect from that panel. So analgesias first. You've seen this picture before, pain, agitation, and delirium. They're all connected, and getting that pain treated first is really important. Coming soon is the best practice guidelines in pain management from the American College of Surgeons, and those were completed last year. I had the privilege of being part of those. I'm hopeful that they'll come out about the time that our TQIP conference would happen in the fall, but stay tuned. Hopefully those are coming soon. All right, let's talk a little bit about agitation and sedation. I hope I'm not going too fast. It's hard when you can't see folks, but I don't see any questions. So once again, if you have questions, please put them in the box, in the question and answer box. This is an interesting patient here in the picture. What do you think about? I'm sure you've seen patients like this. Their legs are hanging over the bed, and they make you kind of squirmy inside because they're squirmy. And as we start off our discussion about agitation, I would challenge you to think about that patient differently because most folks would think, oh, I need to put that person back in the bed, and then I need to think about restraints or think about a way to keep that person in bed. And I would challenge you to think the patient has their legs over the edge because they're ready to get up. Are we ready to get them up ourselves? Is it time for that patient to move? As Christine said, I did my dissertation on early mobility, and so I have a different vantage point of trying to get people moving, get folks up and going. And so when we start to think about the patient that may be agitated, think about if there's a physiologic cause for that agitation and examine the patient. Put your hands on the patient. Talk to them. See if you can figure out what's making them agitated because some of the most common things can cause that. The patient can be cold. The patient can be hungry. The patient may need to have a bowel movement, lots of different things. Is the patient comfortable and pain relieved? Think about those things, and is the patient disoriented or has a lack of sleep? And so all things to consider before we begin to think about different medications that can be used to keep the patient calm and not agitated. So very important to think about where are we and where we want to go with our patient in thinking about agitation and sedation. And just to give you an example of two different patients, if your patient was 26 and in a motor vehicle crash and was intubated because of decreased GCS, because of drugs and alcohol but has no traumatic brain injury, that's a different patient than the patient who's had very critical resuscitation, been hypotensive, has an open belly after surgery and is going to be going back to the OR in the next couple hours. Very, very different path of how sedated you want that patient to be, what the plan is for the next few hours. And so that's very important to articulate to the team and have everybody know what the plan is and where we're going from here. Our assessment of sedation, I'm sure you're used to looking at those. We could have done a polling question about this too, what people are using for assessment of agitation and sedation. We use the RAS score in our institution and very familiar with that. And these are the two scales that are recommended for use from the Society of Critical Care Medicine. So what's the target? That's the most important thing to know. For our nurses, for our physicians, APPs that are caring for patients, where do we want the patient to be? How sleepy do we want them? And the suggestion from the guidelines is that we target light sedation versus deep sedation. And with that then will come shorter times to extubation, reduced tracheostomy rates. But there is a need for randomized control trials to evaluate outcome data related to those practices. In thinking about the target and communicating the target, everybody's view in your electronic medical record is not the same. And so it is something to think about when you're trying to communicate that target and how everybody sees it. When a provider enters an order, in our institution this is what it looks like. We use EPIC as our electronic medical record. And you can see very closely that our target titrate by increments of 0.1 mic per kilogram per hour every 30 minutes to maintain their RAS 0 to negative 2. We did these goals. It's probably been more than five years ago when we set these panels up. And so that can be edited and it can be changed. And so that then is clear from the provider that's prescribing what the target is. However, when you get to the medication administration record, this is the view that the nurse has. And so you see how it looks. And I don't know if you can see my pointer when I use it. But down here in little font, maybe that's about nine font, something like that, is the administration instructions. In our medication administration record, the administration instructions are closed. And so the nurse has to click on that in order to open that administration instructions with the target. So it's not always easy to see, not always very visible. It takes a step by the nurse to see that. We have gone to our rooms have in our ICU have glass walls, glass walls with blinds. And we use those glass walls to write. And we will write what our target RAS is for the day so that the nurse can see it very, very clearly. Because this is somewhat hidden in the medical record. It's something that we're still working on, whether those administration instructions can be open all the time instead of closed. But again, a process issue that makes everyone's view not the same when you think that you're clearly communicating the target. It's not always easily seen by others. So do you have problems with your ventilator length of stay? When you look at it in comparison to other hospitals within TQIP, is your ventilator length of stay longer? Then you need to look at how is the communication between the team in the ICU? Are they talking about what the plan is for the day? And on rounds, do you have other folks involved? Do you have respiratory therapy? Do you have PT and OT? How are we doing with pain control? And how are we doing with our sedation? It should be that we're discussing what our target is, where the patient is, what their CPOT or BPS score is, and then looking at spontaneous awakening trials and spontaneous breathing trials and how that's doing, how we're coordinating that between the nurse and the respiratory therapist. I would recommend that everybody do an audit. Actually see how you're doing in that coordination of SATs and SBTs. We did this. It's probably been more than two years ago. We were part of the ICU Liberation Collaborative, and we actually timed. We looked at the timing between when the nurse did the spontaneous awakening trial and when respiratory therapy was doing their SBT, and found that respiratory was starting their SBT sometimes way, way before at the spontaneous awakening trial. And so we got that maneuvered and moved back around and then worked on our rounding so that our rounding was timed very closely to the time after those SBTs were started so that we could see the patient during the SBT. We could talk about whether they were doing well or they were failing. And then we did some changes in our flow sheets as well so that we could capture the reasons for failure so that we could see them very closely, and we could talk about how to work to improve conditions for the patient and be able to trial that patient again. Some things about spontaneous awakening trials from working with nurses very closely. Sometimes they're afraid, and they're afraid to turn medication off. I think that's changed as we have become more used to having patients more lightly sedated, but we do have some patients sometimes that nurses are a little afraid of. And so we do use the buddy system. We talk back and forth. You know, the nurse might say to the nurse in the next room, I'm getting ready to do my spontaneous awakening trial and spontaneous breathing trial. I'm going to be more in my room. Where are you going to be so that they know what's going on? Some patients are just tough, and they are tough to have sedation turned all the way off. And so we have to remember that it is a procedure that saves patients' lives. And from different studies, we know the number needed to treat is seven. And doing spontaneous awakening trials and spontaneous breathing trials together saves the life when you're doing it in just seven patients. So that number needed to treat is just seven. Ensuring all the time that pain is controlled during that time and home meds are reconciled, which we talked about. What about pain medicine during spontaneous awakening trial? That's always a question from new nurses, and we've actually put it in our policy so that they know if we have something that's continuously infused or an intermittent opioid, that that is okay to remain on if the patient's having active pain. And so it can be left on for that spontaneous awakening trial. If the pain is felt to be controlled, meaning they have a CPOT that's less than 3 or that numeric rating scale is less than 4, then the analgesic should be stopped. That opioid should be stopped, turned off, not paused, but always off. And then we err on that side always of making sure the patient's got good pain control. But we turn it off and then think about whether we need to have it back on and turning it back on at half. I have one question over here. Oh, awesome. Are there any side effects to be woken up like PTSD on these patients? Okay, that's a great question. And so, actually, it's a funny thing to say to be wakened up because we know that, first of all, the sedatives that we use don't, are not correlated with sleep or the same kind of sleep that you and I have, hopefully, when we sleep at night. And we're keeping patients lighter. But we also know that keeping patients lighter and having them have a realistic view of what's happening and more recall of what's happening actually is associated with less PSTD, PTSD, sorry. So, if they can remember things that happen more clearly, then they have less PTSD. And so, we'll talk a little bit about that with delirium as well. But I always, since I told you I had worked with the pharmacist, Mary Jo, she talks in my head all the time, but she says, my drugs are always an issue. And so, the less drug that we can give to patient, the less changing of their perception of their reality, the better that they will be. I hope that answers that question. So, onward, we talked a little bit already about spontaneous breathing trial. Real important for that to be coordinated with the SAT. And then, for us to find out why the patient did not tolerate it so that we can work on repeating that at a later time. And sometimes, we'll do more than one of them a day. We might try them in the morning and then do it again in the afternoon. So, less is more. Less drug is better. Lighter is better. Moving is OK. And getting the patient moving and being able to sit up, sit in a chair while still on the ventilator, that's really great. And that less drug, it goes back to your question, helps us with decreased length of stay in the vent, decreased ventilator-associated pneumonia, which we'll touch on hopefully, decreased delirium, and decreased PTSD. All right. So, the question, do you use BIS monitoring to correlate your assessment tools to confirm increased mental status? And so, we do not use BIS for patients that are intubated unless they're on paralytic drugs. And so, if we're using a paralytic, we don't use them very often at all. In my previous job, we used them for patients that were being cooled. And we did use a BIS monitor to help us with looking at mental status. So, hope that helps you. Thanks, Scott. I like your question. So, a little bit about delirium. Delirium is a new complication for us, 2020, for TQIP. And I think this got snuck in a little bit. It wasn't snuck in. It was just that our lovely beginning of the pandemic started. And I think our usual focus on what are new complications, watching them, our focus kind of strayed a little bit. And we got to thinking about other things. This is the definition from the NTDS. It's defined as an acute onset of behaviors characterized by restlessness, illusions, incoherence of thought and speech, can be traced to one or more contributing factors such as severe or chronic medical illness, changes in metabolic balance, medications, infection, surgery, or alcohol or drug withdrawal. So, that's our definition. It remains the same for 2021 as well. This is the definition that I'm used to looking at. And that is an acute change in consciousness that's accompanied by inattention and either a change in cognition or perceptual disturbance. And so, I really like that, the way that says it. It's an acute change. It's a change that happens over the last 24 hours. And it is accompanied by inattention. And we'll talk about that. There are three subtypes. Patients can be hyperactive, hypoactive, or have a mixed motor subtype that's both. And we know that delirium is really associated with increased mortality, increased length of stay on the ventilator, increased time in the ICU overall, increased reintubation, increased long-term cognitive impairment, and then more patients will go to a long-term care facility as well. All right. I knew that polling question was coming. So, what delirium assessment tool do you use in your hospital? Let's kind of get a good sense for this. Christine, you should have a little music while they're voting and they're counting. That would be fun. Yeah. Don't, yeah, don't make me sing or anything. I can't do that. Okay. Let's see. So, 74% of you are using CAM. And 3% are using a hospital-built ICU checklist, which is cool. 3%, really small number of you using the intensive care delirium screening checklist. And 21% of you are unsure. So, that's cool. That's great. That's good to know. So, does your patient have delirium? We're going to talk about what the abstractors, our registrars can pull to record that complication, but you should have a good sense. If you're working, we had a lot of nurses that are on the webinar this afternoon. If you're walking around in the ICU during that time of nurses doing their assessment and you're using the CAM, then the CAM and both the intensive care delirium screening checklist both use this piece of the assessment where you hold the patient's hands and you have them squeeze on the letter A. And then you use the SAVE A HEART kind of acronym for them to squeeze every A to see whether they're paying attention and they can stay focused on you and follow the commands. You should be able to hear that. You should hear the nurse saying that to the patient, having them squeeze so that you know it's being done. The other way that you know is when you're rounding on the patients with your team and you're asking, is the patient delirious? And the person who's done their assessment pauses and says, they are a little delirious. It's a little bit like being a little pregnant. You're either delirious or you're not delirious. And I think it's really hard to tell unless you use a validated tool. And so, unless you're using the CAM or you're using the intensive care delirium screening checklist, I think it's more subjective. And that's my opinion. So, this is a picture of the CAM and it looked like there was a good percentage of you that are used to using that. It is something that I think is, it's not easy for nurses to learn. It's not easy for other professionals to learn. You have to do it and you have to do it with lots of patients. It's a good practice to learn and have someone do it with you and then do it on different types of patients so that you begin to think about it. How is it with this type of patient? How is it with this type? How about folks that are on the ventilator versus not on the ventilator so that you get used to scoring it and figuring out what the results are? There's great videos on the icudelirium.org website, which is from Vanderbilt. And the training manual for the CAM is also on their website. And I would encourage you to read that as we look at the complication of delirium for T. quip starting this year. You know, I would hope that in our fall report, we'll get some comparison of how we're doing as a center to other centers across the nation so that we can see what our odds ratio is. I was looking for that word that I don't like, odds ratio, how we're doing with that in comparison to others. I would encourage you to read the training manual specifically on page 16 if you're using the CAM, and how it relates to brain injured patients. Because when you look at feature one, feature one really looks at what their baseline was. And we usually think about the patient's baseline, what they were like at home before they came into the hospital. Our patients that are brain injured are different. And so we have to figure out what their new normal is. It's very difficult to figure out whether their fluctuations in mental status, their acute change is related to their traumatic brain injury, or it's delirium. And so there's some specific wording and recommendations in the training manual about working with brain injured patients. And using wording in your progress notes or your notes if you're a nurse that say the patient exhibits symptoms of delirium instead of just saying delirium. Because it's difficult to figure out what that baseline, that new baseline is. I hope that makes sense. All right, that's just a picture of the intensive care delirium screening checklist, just a little bit different. And again, questions that you do over the course of your shift, both of these, it's important to remember that sometimes folks think that you can't do the assessment when patients are on sedation, and you very much can, as long as the patient can start to interact with you. And so if the patient is unresponsive in those deeper levels, if you're using RAS, patients who are negative four or negative five, you cannot use the tools because they can't interact. All right, a little bit about trauma patients. This is just an interesting study that was done that I tried to look at some things that are very particular to our trauma patients. And what is the predictive factors more so for trauma patients? And we know that patients that are mechanically ventilated, those that have sedatives and analgesics, those that have lower RAS scores and higher illness severity, that there's a higher correlation with the development of delirium in these patients. So we really have to cue into that assessment. Make sure that it is a consistent practice. I'll show you a screen in just a little bit of how you can look at it, what you can think about. We have to reinforce that that assessment's valid when the patient's on continuous analgesic and sedatives, we have to use a validated tool. And then, again, talk about what the patient's baseline is. Is the baseline new since their injury? And how do we continue that assessment as we're caring for them? So one of the ways that we are going to abstract that information from our medical record is that the diagnosis has to be documented in the medical record. And it's just an example of one of our discharge summaries where one of our providers put in their discharge diagnoses that the patient had acute delirium while the patient was in the ICU. And so it can be documented in the patient's medical record. It can be that they test positive using an objective screening tool like the CAM ICU or the intensive care delirium screening checklist. Or, and this is the picture from the TQIP video that teaches folks how to look at that complication. It is also, can be abstracted from documentation of physical signs and symptoms. So that's really important. I think our registrars are using mostly that diagnosis of delirium and looking for that in the provider's progress notes. But it can be pulled from these three areas. We do exclude patients whose delirium is due, DUE is supposed to be, to alcohol withdrawal. So kind of going to be interesting as we go forward looking at delirium as a complication in our trauma patients. So look at how your flow sheet is set up. And interestingly enough, today at 2 o'clock there was a webinar from Epic that was about how your ABCDF bundle can be implemented in your medical record. It is recorded. This is not a commercial for them or anything. But if that's something that you're interested in, you can get in touch with your Epic rep. But these are two that I pulled off of our flow sheets. And just know how they're set up. So ours is set up so that feature three, which in our institution is where RAS comes in, automatically translates depending on the score as negative. And then if they score a RAS negative four or negative five, it automatically populates with that unable to assess. And so it's just interesting to know exactly how your things are set up because there are screens behind so that you can look at it. It's important also to do an audit of these. If your abstractors are going to be able to pull from these flow sheets to document delirium, first of all, they'll have to know where they are to look for them. And then you'll have to make sure that they're correct. And so we're beginning to look at, we did some, lots of education when we introduced CAM. And then we've done some spot checking. But we're going to be doing some additional spot checking as well, knowing that our registry is going to be looking at these flow sheets. So next steps, I think the most important is when your CAM ICU is positive or if you're using the intensive care delirium screening checklist, meaning that the patient is delirious or has symptoms of delirium, that you're thinking about potential causes and interventions and using this stop and think. That's been put out multiple places. I really, really like it. We keep it on our bulletin board in the ICU so that we think about whether any meds need to be stopped or lowered. It's different than folks instantly thinking about medicines that we might add. And often, when patients are delirious, especially if they're agitated, we think about changing that behavior, calming that behavior, adding sedation. And so we don't think about are we giving them too many meds and changing their interpretation of their environment. And so think about whether they can be stopped or lowered. Can you, you know, stop it and do your daily sedation cessation or your spontaneous awakening trial? Do you need to change to something else? Does the patient have good pain management? And then that think part, the letters of think stand for different things. And what I would say is I always think that delirium heralds some new problem. It comes, especially if it's an acute change, it heralds something else that's happening with the patient physiologically, a chemical change that's happened in their brain because of something else that's going on. And so think about toxic situations, CHF, shock, dehydration, new organ failure, such as liver or kidney, is the patient hypoxemic? Infectious sources, such as a UTI, that is a common cause of delirium. Immobilization can cause it. And then you always want to think about those non-pharmacologic interventions that you can start, you can't say that is some of the most important things, making sure the patient has hearing aids in, glasses, that you're keeping the room light during the day, keeping it dark and quiet at night, and helping with sleep protocols and getting uninterrupted sleep, and then getting the patient moving, ambulation. Potassium or electrolyte problems is that last K part of that, so that stop and think, really, really nice summary of what to do when your patient is delirious that's helpful. And helpful so that it keeps providers from thinking about what medication can be started, which is often where we go. We need to watch coming research and evidence so that we watch for the studies with different drugs. We know that no drug's been approved by the FDA to treat delirium, that Haldol does not decrease the duration, and that atypical antipsychotics are being studied and may help to decrease the duration. We use a lot of Seroquel in our institution. A lot of times we just need to figure out, are there things that we can do in that stop and think type of mentality that will help? The other thing that I really advocate for is selecting the nurse that's going to take care of that patient. Because if you have a patient that is agitated or moving, you have delirium, there are different people that are more tolerant of that and can work with the patient. And so matching that patient with skills of the nurse, sometimes that can really help and allows you to use less drugs and to move that patient forward. Dr. Campbell, I just had another question in the chat. Awesome. From Kelly Evans, she wants to know if Epic is the only electronic medical record vendor that offers tutorials on flow sheet charting for the A to F bundle delirium. You know, I don't know the answer to that, but I would imagine that they are not unique in that, that if you contact your vendor and ask them, I'm sure because the ABCDF bundle has been out for many years now, that they have worked on that with their institutions. And so I would urge you to contact your vendor for your EMR. So going along with the bundle, E is early mobility, one of my favorite parts and keep calm and stay mobile. Patients are meant to move. Our patients are tough because their legs are broken, their pelvises are broken. And so we need to figure out what their weight bearing status is. We need to get their spine and the bones back together. And so as soon as we know what weight bearing statuses are and we can, we need to start working. So we have PT and OT and speech every day in our rounds, getting to work with that patient as soon as we can. So that's really important. We often will, if a patient doesn't tolerate spontaneous awakening trial and spontaneous breathing trial, we may try them later in the day. We may get them up to the bedside. We may get them to a chair so that they are more awake, but still on the vent. And sometimes just that erect posture and keeping that chest upright can make it successful for them to pass both the SATs and SBTs. So collaboration, really, really important. This is one of my patients that was involved in early mobility in my dissertation. This is actually his picture and I have permission to use it, but these are his quotes and about early mobility. And he walked on the ventilator and he said, you know, I was ready before you were and I wanted to walk farther than you wanted me to. But you were nervous. You can imagine the patient saying that is so funny. And he said it gave me something to do and it gave me hope that I was going to get better. And so sometimes we're worried and we misread the signals. That signal of the patient's leg out of the bed may mean I'm ready to go. We're not ready yet, but we need to to not miss that cue from the patient. Family involvement, this looks like this is a picture that I pulled off the Internet, but lots of people in rounds. And often we have that many people in our rooms, not so much since the pandemic started and we've been limiting visitors. But we do try to get people as involved as possible. We're using the ICU family diaries and using some very purposeful family meetings, especially in those patients that are severely injured. So that we get good conversation with our families, good rapport and then good decision making as well. We do have another question on your last slide. No, that's fine. How do you keep how do you keep the patients from falling forward in the chair? Some sort of restraint or a chair position that that can be changed to. So we have we can change the position of our chairs to put their back a little bit back. Our our beds also go up into that chair position. We prefer getting the patient out of bed, though, because it's something about that patient putting their feet to the floor that changes the awareness of their surroundings and the awareness of their body to to make them be more awake. It requires a more awake patient to do these things with. And so your your patient can't be heavily sedated because they'd be like a total lift to get out of the out of the bed and into the chair. They have to be very much able to follow commands. So just one last slide, and it's about ventilator associated pneumonia in our state of Ohio. We've been talking a lot about that because it was our highest complication in those centers that participate in T-QIP in our Ohio T-QIP group. And what we found in in talking is that folks are not using the NTDS definition. And so I would encourage you as you go through the year to really look closely at that definition. I know there is a challenge between infection control in your hospital and them using the current CDC version definition and that being disparate from what trauma uses. But it really does help us to have apples to apples comparison in our T-QIP centers instead of an apples to oranges comparison. We know this year we're using 2016, the CDC definition next year for the NTDS data dictionary that moves to the 2019 definition. But I would encourage you to look closely and to use that definition for the T-QIP complications that you enter so that we can get that comparison of apples to apples across our nation. So, all right, I see another. This is my last slide. I see another question from Scott. How does your staffing with PT and OT and nursing affect your ability to get patients up? Do you triage to trauma patients and weekend differences? And so, yes, we have weekend differences. We don't have as much staff on the weekend. But we do prioritize and talk about those patients who are ready to get up. Who can we get up so that we do that early in the day? We meet every day, every morning with PT, OT, and speech. We do it now on Microsoft Teams. We used to do it in one room together so that we run our patient list and we talk about them. And then we talk about them in the patient's room as well. And so, we have close coordination. But in the unit where I used to work was a 29-bed mixed med surge every morning. I ran the unit, ran the unit list with PT and OT so that we knew who was on the list to get up. Usually, nurses would be telling me, this patient's ready, this patient's ready. And then as we rounded on them, we might identify other patients. But that good communication is really the key. We have specific trauma rehab folks that are part of our team. Hope that helps your question. All right. I have a question in the chat. OK. Awesome. I cannot see that if you read it. Sure. What do you use so that patients are not gagging on the ETT? So, that's a common problem. And so, we use the holders that go on the side of the face. So, they do keep it very secure. It's a common problem. I don't know that we have any specific thing. When the patient begins to gag and they're becoming more and more awake, we begin to move more towards spontaneous awakening trials and spontaneous breathing trials to see if we can move the patient towards extubation. OK. I don't have any other questions here. Any other questions? I know it's been a review of a lot of content. I tried to pull some of the things very specific to trauma out for us. I hope it's been helpful for you. I appreciate your listening and your participation in the polling and in your questions in the chat and in the question and answer box. I hope you have a great, great day. Thank you, Dr. Campbell, so much for being with us. And we really do appreciate it. If anyone has things of any other questions after the webinar ends, I can always forward them on to Dr. Campbell via email. And I've put in the link to our evaluation in the chat box. But I'll also be sending out an email with that link. So, thank you, everyone, for attending. Thank you again, Dr. Campbell. And have a great rest of your day. All righty. Thanks. Bye-bye.

ICU best practices

trauma patients

pain assessment

sedation

Richmond Agitation Sedation Scale

spontaneous awakening trials

spontaneous breathing trials

delirium

CAM

early mobility