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If you are one of the 5.7 million Americans who end 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 caused by Alzheimer's disease or a traumatic brain injury and many patients never fully recover.
But research shows you are less likely to suffer than if the doctors and nurses follow a procedure that is 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 temporary state of mental confusion characterized by a lack of focus, difficulty in understanding what is going on around you and sometimes hallucinations.
Following this checklist of actions can reduce the risk of mental impairment following ICU stay by 25 to 30 percent, says Dr. E. Wesley's "Wes" Ely at the Vanderbilt University Medical Center. (This post-ICU is a condition of the problem that can arise after heart surgery and general anesthesia in the elderly).
It is not simply detailed medical care – it's a philosophy.
"I think the most editable 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 allow the family, and allow them to subsist in delirium. "
When Ely started in the ICU years ago, he made every doctor made different decisions about how to get to know the patient. He figured those small decisions might be having a big impact on the patient's recovery. So he gradually builds an evidence-based checklist of the best way to handle basic tasks that most quickly get patients back on their feet.
First, medical researchers developed a system when it was safe to take a patient off ventilator. Next, Ely says, "we started standardizing how to remove people off of sedation, then we came up with a way to measure 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, has recently been treated to Vanderbilt with five failing organs – his brain, heart, liver, lung and kidneys.
His saga started out in Los Angeles, where he lives. He had eaten a sandwich that he suspects had gone bad. The next morning, he hopped to visit his son in Nashville.
"We just did not 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 could not convince him to go to the doctor's side. He was rushed to the closest room to his son's house, half-hour from Nashville.
"They started putting in tones of [IV] "Karen recalls," "It's all about you." Imagine the shock when you go in there [doctors say] 'Oh, every organ is shutting down.' "
O'Burke was in septic, 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, it 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," says Karen, "and that was not a good thing."
She says when the doctors told her to start calling, she knew it was going to be better. That's how it ended up at Vanderbilt.
Within 24 hours of his arrival, Randy's condition had turned around completely, Karen says. He was off the dialysis, the ventilator, and off the drugs that led 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 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. "But just the fact that I can carry on a conversation right now is pretty amazing in itself."
As part of this faster 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 to O'Burke's recovery. Overlaid on the bundle of steps to reduce delirium. Those are now in the checklists that nurses, respiratory therapists and doctors use every single patient they treat at Vanderbilt.
"Ely tells the O'Burkes," 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 significant difference in motivating patients to be alert and moving about.
Ely explains that this bundle of procedures is a big change from what many still do, which is to knock out a patient and treat their dysfunctional body, rather than focusing on them holistically.
"To me the 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 to the problem of survival and decrease in the time of delirious or in a coma.
Ely is leading author of another study, involving a network of critical care units that enrolled 15,000 patients. Findings from that soon-to-be published study add more support for the practice, Ely says.
Gradually, the bundle of techniques has been adopted in many recent years, Ely says, but is 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.
"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 may need more time and attention if they're alert in bed or 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." "We were able to buy that, then you have to buy from the doctors."
That's harder in a community hospital, he says, where physicians are more independent and can do rounds three days a week.
The ideas slowly took hold, he says, though there is still resistance to using the "A through F" checklist to make sure every element is attended to every day by every patient.
Voelker says, "but actually going through and saying 'ABDCEF' is the exception."
It was 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] This project is helping me to make it happen, and I'm sure it's going to happen every day. "
Ely's mission is to make it's standard around the world. For one thing, it can actually reduce the cost of care, he points out, by reducing the amount of time spent in expensive ICU units.
"But the most important thing, of course, is not the money, it's the human being," he says. "So they're getting better care, surviving more – often with a more intact brain – and not bouncing back to the ICU … to get me that's a win-win."
You can contact Richard Harris at [email protected].
Copyright NPR 2018.9(MDAyNzUwMDI2MDEyNTA3MTU5NzcyNTQyNA004))
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