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Decreasing sedation, improving delirium management, and increasing mobility are key ways to improve outcomes for critically ill patients.
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Rethinking Sedation, Delirium, and Mobility for ICU Patients

By Kelly McCutcheon Adams | Thursday, April 23, 2015

IHI Director Kelly McCutcheon Adams describes her passion for IHI's work on preventing complications for ICU patients and how it led to an article published in the Joint Commission Journal on Quality and Patient Safety. Adams is director for the Rethinking Critical Care: Reducing Patient Harm from Sedation, Immobility, and Delirium seminar.

KellyM

Because I’m a clinical social worker by profession, my colleagues at IHI often make assumptions about the topic areas that will appeal to me the most: patient- and family-centered care, health disparities, self-management, etc. They are surprised to learn, and so was I, that what I’m most passionate about is some of the most clinical work I have encountered in my decade as a Director at IHI: the reinforcing and harmful intersections in critical care of over-sedation, under-recognized delirium, and immobility.

My passion for this work began almost six years ago. A few months before the final session of IHI’s Improving Outcomes for High-Risk and Critically Ill Patients Learning and Innovation Community in 2009, a member of one of the participating teams emailed me. Since we were meeting in Nashville, she suggested I contact Dr. Wes Ely, a leader in critical care from Vanderbilt, to see if he would be willing to speak at our meeting about their ICU delirium work. I assumed Dr. Ely would not have time for this invitation, but within an hour of emailing him, he had called to ask how he could help. He and members of his team gave an engaging presentation about the harm of delirium and how to more reliably recognize it by using the CAM-ICU tool.

The ICU Community teams found Vanderbilt’s presentation very useful. The turning point for me, however, came when I listened to conversations between Dr. Ely and long-time IHI faculty Dr. Terry Clemmer and Vicki Spuhler, RN, both of Intermountain Healthcare. Dr. Clemmer and Ms. Spuhler helped IHI develop the Ventilator Bundle and Central Line Bundle. Throughout the years of the ICU Community, they spoke passionately about the harm of over-sedation and the work they were doing at Intermountain to get ventilated patients up and walking. We had seen photos of this work, but I think most of us still harbored disbelief about it. As I listened to these three absurdly smart people speak about the interconnections of their respective passions, it was like watching lightning bolts pass between their brains. The conversation made a big impression on me. In my own work as an ICU social worker, I believed what I had been told about why it was important that patients be so deeply sedated and consequently immobile. That logic was unraveling in front of me, and I began to understand the scope of the harm clinicians were unintentionally doing to patients.

My excitement about this work stayed with me, and in 2011 I was fortunate to lead an IHI “live case study” visit to Intermountain Healthcare and see the work of Dr. Clemmer and Ms. Spuhler in action. Dr. Ely joined us as faculty and 30 participants came along for the experience. Seeing ventilated patients up and walking inspired us all. How could it be that this was the exception, not the rule?

We took the energy from that experience and used it to drive the creation of IHI’s Rethinking Critical Care seminar, which was offered five times between 2011 and 2013. The exciting work from those seminars inspired us to write a case study paper featuring five participating organizations. Although I often joke that an elephant could have been gestated in the time it took to finish the paper, the experience of writing my first journal article was a labor of love. It is a real joy to see these case studies in print in the Joint Commission Journal on Quality and Patient Safety, in the article titled “Rethinking Critical Care: Decreasing Sedation, Increasing Delirium Monitoring, and Increasing Patient Mobility” (February 2015). We hope these organizations’ journeys and their practical advice will inspire others to undertake this important work to reduce harm for our vulnerable critically ill patients.

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