 We are here today talking with Kaylee Dayton. We're going to talk about early mobility and patients who are on a ventilator. Kaylee is a critical care nurse practitioner. She's also a podcast host of the podcast, Walking Home from the ICU. Kaylee is very passionate about preventing delirium and preserving physical function for patients who are on the ventilator. So welcome Kaylee. Thank you so much for joining us today. Thanks for having me on Donna. Kaylee, I wonder if you tell us just a little bit about your background and why you're so passionate about this topic. Yeah, I started my nursing career in what I call now on the podcast, the awake and walking ICU. So that was my first introduction into ICU medicine, and I thought it was completely normal to have almost every single patient on a ventilator awake, communicating, autonomous, interacting, and usually walking on the ventilator. So I spent a few years in that ICU and then I became a travel nurse. And I started going around the United States and it was suddenly immersed in this normal culture of deep sedation and immobility. And I had a really hard time understanding why they were doing it and they couldn't understand why I was trying to wake people up. And it was just, it was difficult. And I still didn't know no one had really taught me why the awake and walking ICU did what they did. And I didn't have the tools to explain to people why it's so harmful to deeply state and immobilize patients. And so when I started grad school, I went back to the awake and walking ICU, I started diving into the research and my eyes were just opened. And every time I learned something about patient outcomes, when I spoke with patients and survivors and learned what it was like during and after their medically induced comas, I kept thinking the ICU community does not know this. They don't understand otherwise they would change, they would treat patients differently. And so one of the ways I found to disseminate that information was through the podcast. And it's been really exciting to see individuals and teams changing their practices because of the knowledge that they've gained from survivors, clinicians, researchers on the podcast. And that's just fueled my passion for implementing the change. Wow, that's great. And you're so right. I love what you said about how it is definitely not the culture. People would be in most organizations would be completely shocked to see a patient walking around the ICU while intubated. So tell us a little bit about this, like where did this program start? When did it start? And what does this program look like? I can't take any credit for it. So this is established at LDS Hospital in Salt Lake City, Utah. Probably almost 30 years ago, it started with a nurse named Polly Bailey. She had followed one of her ARDS survivors out of the ICU. This is in the late 90s. That was when in a time much like now with COVID, they were deeply were deeply sedating, paralyzing, immobilizing everyone on the ventilator for weeks. But she followed one of the survivors in her community out and watched this mother in her 30s spend the next year trying to make it up the stairs, having to use a bedpan in the bed still, being really cognitively impaired, extremely traumatized by the delirium she'd experienced. And so she went back to her medical director who was Dr. Terry Clemer at the time and said, we can't do this to patients. We can't just throw away their lives while we're trying to save their lungs. What if we woke them up and moved them? What if we didn't let them atrophy? And he thought that was completely crazy. But he trusted her nursing instinct and he let her try. And as she did that, she found that patients could be awake and walking on the ventilator and that it changed outcomes. So that was a shock trauma ICU. And as you would expect, it was a tough sale. So they started a respiratory ICU hired nursing home nurses who had no critical care experience. And they taught them the rest. But they started with this fresh culture and just said, we're just going to let people be awake after they are intubated and acclimate to the tube and keep mobile. And we're going to get them off the tube sooner. We're going to prevent delirium. And this is just the way it's going to be. And that's why when I started working there, it was so normal. No one warned me that that wasn't the norm. So what are the outcomes of a program like this? I know obviously the biggest concern that people would have would be unplanned extubation and so on. So what kind of outcomes did you have? And did you have any complications like that? So back in 2007, they published the first study to show that it was safe and feasible to walk patients on mechanical ventilation during acute respiratory failure. And out of, I can't remember a couple thousand activity sessions, there was less than 1% harm event, harm, including hypoxia, hypertension or unplanned extubations. I don't think there were any unplanned extubations. And so it was it is extremely safe. And what makes it so safe is avoiding sedation and preventing delirium. I'm sure we've all seen unplanned extubations, but think who did it? Was it someone that was in their right mind, free of delirium or were they really confused, unsure of their surroundings, isolated, you know, all the risk factors that actually lead to an unplanned extubation. So before COVID hit, they'd gone about two years without any unplanned extubations. And even when that happened during COVID when the patient was isolated had been deeply sedated because they had to be paralyzed for a little bit. They didn't have to be re-antibated because they had been mobilized before being paralyzed, they were being mobilized after they were strong enough to breathe on their own. And so that is the difference of the A to F bundles. Even if there are those few unplanned extubations, they don't have to be re-antibated because they're more likely to survive and be strong because of it. Other outcomes such as discharge disposition are completely different. Within the same hospital system, they did a data collection and compared discharge disposition from the Wakenwalk and ICU to those in an outside hospital with the same Apache scores, almost the same community, 98% of survivors from the Wakenwalk and ICU discharged home compared to 46% in the comparative hospital. They found that if patients can walk over 200, at least 200 feet in the ICU, they are 13 times more likely to discharge home. I wish they had more data collection on how much time on the ventilator is spared. Their re-antibation rate is extremely low. During COVID, they've had no ventilator associated pneumonia. So outcomes, and I'm sure mortality is different. I wish that they had more control groups to compare to because their outcomes are drastically different and their delirium rates are lower. And therefore, subjectively, I think the workload on the staff is much easier because they don't have massive atrophy, big adults, newborns that they have to try to mobilize or turn. They don't have thrashing patients all the time. So it changes outcomes and experience for everyone involved. So I was a critical care nurse 30 years ago when all of this started. And I remember hearing about early mobility programs and hospitals. I'm curious, why did it not take hold? Why are we here now in 2021 and not in every hospital doesn't have an early mobility program? I think it's a really complicated question. I think a lot of it's rooted in culture, which has even deeper roots of education. I think we have this misinformation in our own culture that sedation asleep, that it's more humane, that's more comfortable, that if a patient looks cozy, therefore they are, we have this huge gap between the ICU and post ICU life. And I've had people say, well, our survivors haven't told us that they were traumatized. Well, why would you go back to the place that was traumatizing to you, right? So when we understand what deliriums really like for patients, that they're experiencing realities that are far worse than the ICU abuse, kidnapping, mutilation, just the worst things, then we'll change. But I think we've missed that point. I don't think we really understand what it's like for patients and what their lives are like after what it's like to live with post ICU dementia, post ICU PTSD, what it's like to rehabilitate and try to relearn how to breathe, swallow, sit, walk. We have this culture being very narrow-sided in the ICU. And so sedation seems like it's a lot easier in the moment. And that's why we've stuck with it. It's just been inherited throughout the generations of clinicians. And we don't have enough Polly Bailey's asking why, why not? What if? Or looking at the top of the tower and over being the whole maze of critical care. We're just looking at that one organ. I think if brains had a lab value to show that they were positive for delirium, we would panic, right? When a creatinine goes up, we're like, no, we have to protect the kidneys. But if we could measure, really measure muscular atrophy or delirium brain dysfunction, we would be just concerned about it. And that's what we need to change. We need to understand the why. And then we can focus on the how and truly implement protocols like the ADF bundle. Wow, that is a great point. I love that analogy about being able to measure delirium or atrophy. That would be amazing if we could. But I think just what you've brought to us today and the excitement that you have around this and clearly you've got great outcomes, hopefully that in and of itself are going to change some people's minds and make them say, hey, we need to do this in our hospital. So what advice do you have for somebody who, a critical care nurse, a critical care physician who wants to bring this program into their organization? How would they even get started to do something like this? That's a really big question, a seemingly daunting task, right? Because it's so established, especially in the era of COVID, we've been overwhelmed. It just seems insurmountable. And yet what I'm experiencing in my webinar and consulting services is that it can really start happening with one clinician. So I've had dieticians pull me in for webinars, physical therapists, respiratory therapists, nurse, anyone that's listening to the podcast will say, how do I bring this to my team? So that's really what spurred me on to do webinars, to say, get everyone all the disciplines because it takes everyone having that knowledge, perspective and vision to bring the change. But once everyone's exposed the same information and they know what's possible and everyone wants to do the right thing. So once we have that clarified what the right thing should be and what it looks like, then we can start discussing protocols. And so I think we have tried to implement the EHR and into certain requirements and protocols, sedation vacations, things like that. But I think we have to step back and really make sure that everyone understands the why, how patients are suffering and how that can be prevented. And then we can work on the protocols and how we actually change those steps of our care. And anyone can bring that change, anyone can call me for a webinar or share the podcast with other people and be sharing that message and helping people listen to survivors to change their perspectives and culture. That's great. Well, and Kaylee, I know that you are also on our workgroup and helping to produce both our mobility apps and our ventilator apps. So I know that you're going to bring all kinds of information into into those workgroups and make sure that that that that gets involved in our protocols as well. I hope so. I know I sound crazy in some of the workgroups because a lot of this information is new to people, maybe not new to you after 30 years, but it's new to some people and it sounds like I'm saying the world is flat when I say that most patients can and should be awake and walking on the ventilator. It sounds crazy. And yet that's only because of the culture and experiences that we've been subjected to. Well, you're absolutely right. I don't think it's a crazy idea. And I hope that others are out there watching this and get inspired to do exactly what you have been doing. Thank you so much for bringing all of this to us today. Thank you. Appreciate the opportunity to share it.