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How To Prevent Brain-Sapping Delirium In The ICU

Oct 10, 2018
Originally published on October 11, 2018 9:21 am

If you are one of the 5.7 million Americans who ends up in the intensive care unit each year, you are at high risk of developing long-term mental effects like dementia and confusion. These mental problems can be as pronounced as those experienced by people with Alzheimer's disease or a traumatic brain injury and many patients never fully recover.

But research shows you are less likely to suffer those effects if the doctors and nurses follow a procedure that's gaining ground in ICUs nationwide.

The steps are part of a bundle of actions aimed at reducing delirium in ICU patients. Doctors define delirium as a usually temporary state of mental confusion characterized by a lack of focus, difficulty in understanding what's going on around you and, sometimes, hallucinations.

Following this checklist of actions can reduce the risk of mental impairment following an ICU stay by 25 to 30 percent, says Dr. E. Wesley "Wes" Ely at the Vanderbilt University Medical Center. (This post-ICU condition is separate from memory problems that can arise after heart surgery and general anesthesia in the elderly).

It isn't simply detailed medical care — it's a philosophy.

"I think the most modifiable piece of this is what we do to the patient," Ely says. "And what we do to the patient [that] is dangerous is immobilize them chemically [with drugs] and physically, and then not allow the family there, and allow them to subsist in delirium."

When Ely started in the ICU years ago, he realized every doctor made different decisions about basic matters such as how quickly to get a patient off the breathing machine. He figured those small decisions might be having a big impact on the patient's recovery. So he gradually built an evidence-based checklist of the best way to handle the basic tasks that most quickly get patients back on their feet.

First, medical researchers developed a system to determine when it was safe to take a patient off a ventilator. Next, Ely says, "we started standardizing how to remove people off of sedation. Then we came up with a way to measure whether your brain was delirious or not."

Ely has dubbed this checklist the ABCDEF bundle. Other elements include assessing pain, managing medications, testing patients' ability to awaken spontaneously, and getting them up and about quickly.

Randy O'Burke, 49, recently experienced the treatment regime after he was rushed to Vanderbilt with five failing organs — his brain, heart, liver, lung and kidneys.

His saga started out in Los Angeles, where he lives. He'd eaten a tuna sandwich that he suspects had gone bad. The next morning, he hopped a flight with his wife Karen to visit their son in Nashville.

"We got on the plane and I just didn't feel right," Randy says. He told his wife his stomach was bothering him.

The symptoms kept getting worse once they were in Tennessee. Even so, his wife says, she couldn't convince him to go to a doctor until his symptoms were out of control. He was rushed to the emergency room closest to his son's house, a half-hour from Nashville.

"They started putting in tons of [IV] lines and going to work and doing different things," Karen recalls. It was all a blur to her. "Imagine the shock when you go in there and [doctors say] 'Oh, every organ is shutting down.' "

O'Burke was diagnosed with sepsis, which is a leading cause of death in hospitals. It's the body's overwhelming reaction to an infection. O'Burke's case was so bad, he ended up on a respirator and kidney dialysis. Drugs sunk him into a state of quiet delirium.

"He was supposed to be lightly sedated and he was heavily sedated," Karen says, "and that was not a good thing."

She says when the doctors told her to start calling next of kin, she knew it was time to get him transferred to a hospital better equipped to treat him. That's how he ended up at Vanderbilt.

Within 24 hours of his arrival, Randy's condition had turned around completely, Karen says. He was off dialysis, the ventilator, and off the drugs that put him into a delirious haze.

"Apparently, I'm pretty much of a miracle," he says. The doctors told him that the chance of survival for a patient with five-organ failure is about one in a thousand.

Recovery still lies ahead, as his mildly slurred speech suggests.

"I'm starting to get my faculties about me," Randy says. "My brain's starting to work really good again. But just the fact that I can carry on a conversation right now is pretty amazing in itself."

As part of this more rapid recovery trajectory, ICU nurses got him out of bed as soon as possible.

"I've done laps around this place!" he says.

An enormous amount of medical care went into O'Burke's recovery. Overlaid on that was the bundle of steps to reduce delirium. Those are now baked into the checklists that nurses, respiratory therapists and doctors use with every ICU patient they treat at Vanderbilt.

"Getting you out of bed early ... cuts delirium in half," Ely tells the O'Burkes, as he explains the reasoning behind the bundle. "E" stands for Early Mobility and Exercise. And "F" — having family members present in the room and talking to medical staff — also makes a notable difference in motivating patients to be alert and moving about.

Ely explains to the couple that this bundle of procedures is a big change from what many ICUs still do, which is to knock out a patient and treat their dysfunctional body, rather than focusing on them holistically.

"To me the linchpin of this whole thing is to respect the humanness of each patient," Ely says.

Vanderbilt's protocol, when systematically followed, can make a big difference to a lot of patients. One study involving 6,064 patients showed that the approach increased the odds of surviving and decreased the amount of time people spent delirious or in a coma.

Ely is lead author of another study, with the Society of Critical Care Medicine, which has enrolled 15,000 patients at 68 ICUs around the country. Findings from that soon-to-be published study add more support for the practice, Ely says. (The study is funded by the Gordon and Betty Moore Foundation, which has supported science coverage on NPR).

Gradually, the bundle of techniques for reducing delirium has been adopted at many ICUs in recent years, Ely says, but is still not the standard everywhere.

"About half [of hospitals] from our last survey have been doing some elements of the bundle," he says.

Pulling it all together, A to F, can be a challenge.

"It was not as easy as we expected it to be," says Dr. Kirk Voelker, a critical care intensivist at the Sarasota Memorial Hospital in Florida. His hospital was part of the 15,000-patient study that Ely coordinated.

Voelker says he found that patients can require more time and attention if they're alert in bed or walking up and down the hallways with their respirators in tow.

And for the staff, "we're talking about a cultural change," he tells NPR. "We had to get buy-in from the nursing staff. Once we were able to get that buy-in, then you have to have buy-in from the physicians also."

That's harder in a community hospital, he says, where physicians are more independent and may only do rounds three days a week.

The ideas slowly took hold, he says, though there's still resistance to using the "A through F" checklist to make sure every element is attended to every day in every patient.

The concept behind the protocol has become the rule at his hospital, Voelker says, "but actually going through and saying 'ABDCEF' is the exception."

It was even a challenge to make the protocol routine at the medical center where it was pioneered.

Joanna Stollings, a clinical pharmacist in Vanderbilt's ICU, says when she arrived at the hospital, it was clear what needed to get done, but nobody was responsible for seeing it through.

"It needs somebody to coordinate this, who's going to be here every single day," she says. "And so Wes [Ely] helped me kind of champion this project, to really empower the nurses and respiratory therapists to make sure this happens every day."

Ely's mission now is to make what his hospital does standard around the world. For one thing, it can actually reduce the cost of care, he points out, by reducing the amount of time people spend in expensive ICU units.

"But the most important thing, of course, is not the money, it's the human being," he says. "So if they're getting better care, surviving more — often with a more intact brain — and not bouncing back to the ICU ... to me that's a win-win."

You can contact Richard Harris at rharris@npr.org.

Copyright 2018 NPR. To see more, visit http://www.npr.org/.

MARY LOUISE KELLY, HOST:

People who survive critical illnesses in the intensive care unit often end up with dementia, confusion or other long-term mental conditions. Doctors are coming to realize they can reduce the risk of this damage by changing how they treat patients in the hospital. NPR's Richard Harris has our story.

RICHARD HARRIS, BYLINE: Dr. Wes Ely spends his day at Vanderbilt University treating patients in the intensive care unit. He realized early on that simply saving their lives wasn't enough. Many of his patients developed debilitating mental problems triggered by extended delirium in the ICU. So Ely has spent much of his career figuring out how to reduce that enormous and underappreciated problem.

WES ELY: The patient you're about to see - this was just a few days ago - had a five-organ failure.

HARRIS: He had dysfunction of the brain, heart, liver, lung and kidney.

ELY: And when I say dysfunction, I mean basically failed. They were - none of them were working.

HARRIS: His family managed to have him transferred to Vanderbilt from an outlying hospital.

ELY: They'll tell you the rest of the story. But when you walk in the room, you'll see what we're dealing with now. This is only a few days later.

I want you all to meet Richard Harris.

HARRIS: Hi.

RANDY O'BURKE: Randy.

HARRIS: Randy, nice to meet you.

R. O'BURKE: Nice to meet you.

HARRIS: Randy O'Burke's saga started out in Los Angeles, where he lives. He'd eaten a tuna sandwich that he suspects had gone bad the day before he hopped a plane to visit his son in Nashville.

R. O'BURKE: You know, we got on the plane, and I just didn't feel right.

KAREN O'BURKE: So I asked him, like, you know, what's going on? Do you feel OK? And he's like, it's my stomach. My stomach's bothering me.

HARRIS: His wife, Karen, couldn't convince Randy to go to a doctor until the symptoms got out of control. He was rushed to the emergency room closest to his son's house a half hour from Nashville.

K. O'BURKE: And they just started putting in tons of lines and going to work and doing different things. I'm kind of a blur as to what was happening at that point because you imagine the shock when you go in there, and they're like, oh, every organ is shutting down, and he's completely sepsis.

HARRIS: Sepsis is a leading cause of death in hospitals. It's the body's overwhelming reaction to an infection. O'Burke's case was so bad the 49-year-old man ended up on a respirator and dialysis. Drugs sunk him into a state of quiet delirium.

K. O'BURKE: Because he was supposed to be lightly sedated, and he was heavily sedated. And that was not a good thing.

HARRIS: Karen says when the hospital told her to start calling next of kin, it was time to get him transferred stat to a hospital better equipped to treat him. Within 24 hours of arriving at Vanderbilt, Randy's condition had turned around completely. He was off dialysis, the ventilator and off the drugs that put him into a delirious haze.

R. O'BURKE: Apparently I'm pretty much of a miracle, so...

K. O'BURKE: Yeah, he said that you were...

R. O'BURKE: One out of a thousand.

K. O'BURKE: One out of thousand.

HARRIS: Recovery still lies ahead.

R. O'BURKE: I'm starting to get my faculties about me. And my brain's starting to work really good again. But just the fact that I can, you know, carry a conversation right now this is pretty amazing in itself.

HARRIS: And you've actually been up and walking around a little bit.

K. O'BURKE: A lot.

R. O'BURKE: Oh, yeah, I've done laps around this place.

K. O'BURKE: (Laughter).

R. O'BURKE: Eighth floor, anyway. I mean, I'm not going to...

(LAUGHTER)

R. O'BURKE: Don't let me exaggerate too much. But yeah, I've walked quite a bit.

HARRIS: Dr. Ely returns to the room and explains to the O'Burke family what he'd done to help bring about this dramatic change. It wasn't just good medical attention. It was a philosophy.

ELY: You know, when you get on an airplane, you get safely to the next location because the airline industry has a checklist.

HARRIS: When Ely started in the ICU, he realized every doctor did things differently. And he figured they can't all be doing the right thing. So gradually he started building a checklist of the best way to handle basic tasks. First they figured out when it's safe to take someone off the ventilator, he explains. Then...

ELY: We started standardizing how to remove people off of sedation. Then we came up with a way to measure if your brain was delirious or not, which - you got that measurement. And we were doing this to you when you were there. We were measuring whether or not you were delirious. And you were at the beginning.

HARRIS: Ely came up with a list of six steps to take in order to reduce delirium and return patients to health as quickly as possible.

ELY: We put all of this into a bundle which we now call the ABCDEF bundle.

HARRIS: That bundle includes close management of drugs like sedatives which can cause delirium. Patients are tested daily to see if they can wake up and if they're ready to get off the ventilator. F is for family engagement. Ely says these all reduce the amount of time patients spend delirious, and that in turn markedly reduces their risk of long-term brain damage.

ELY: Getting you out of the bed early, that E part, is - cuts delirium in half. So these things are all intersecting.

HARRIS: As he sits on O'Burke's bed, Ely explains that it's a big change from what many ICUs still do, which is to knock out a patient and treat their dysfunctional body rather than focusing on them holistically.

ELY: To me, the linchpin of this whole thing is to respect the humanness of each patient.

R. O'BURKE: Thank you again.

ELY: I love it.

R. O'BURKE: Thank you.

ELY: Thank you.

HARRIS: The bundle, when done correctly, reduces the risk of ICU-triggered dementia by 25 to 30 percent, Ely says. That makes a big difference to a lot of patients. It's gradually been adopted at ICUs in recent years, but Ely says it's still not the standard everywhere.

ELY: About half from our last survey have been doing some elements of the bundle.

HARRIS: Pulling it all together A to F is a challenge. Dr. Kirk Voelker at the Sarasota Memorial Hospital in Florida discovered that when he took part in a nationwide study to expand the use of the bundle in all sorts of hospitals.

KIRK VOELKER: It was not as easy as we expected it to be in a couple of aspects.

HARRIS: Patients require more time and attention if they're alert in bed or walking up and down the hallways with their respirators in tow.

VOELKER: We're talking about a cultural change. So we have to have buy-in from the nursing staff. Once we were able to get that buy-in, then you have to have buy-in from the physicians also.

HARRIS: That's harder in a community hospital where physicians are more independent and may only do rounds three days a week. Gradually the ideas took hold, he says, though there's still resistance to using the A-through-F checklist to make sure every element is attended to every day in every patient.

VOELKER: I think in concept, it's the rule. But actually going through and saying, A, B, C, D, E, F is the exception.

HARRIS: It was even a challenge to make it routine at Vanderbilt.

JOANNA STOLLINGS: What the problem was is there wasn't a champion.

HARRIS: Joanna Stollings, a clinical pharmacist at the ICU, says when she arrived at Vanderbilt, it was clear what needed to get done, but nobody was responsible for seeing it through.

STOLLINGS: It needs somebody to coordinate this who's going to be here every single day. And so Wes helped me kind of champion this project to really empower the nurses and respiratory therapists to make sure this happens every day.

HARRIS: Wes Ely's crusade now is to make what this hospital does standard around the world. For one thing, he argues it can actually save money by reducing the amount of time people spend in expensive ICU wards.

ELY: But the most important thing of course is not the money. It's the human being. And so if they're getting better care, surviving more often with a more intact brain and not bouncing back to the ICU, we see some financial benefits. To me, it's a win-win.

HARRIS: Richard Harris, NPR News. Transcript provided by NPR, Copyright NPR.