ICU Liberation and COVID-19: Women Leaders in Medicine, Ep. 4
This podcast series aims to highlight the women leaders in medicine across the United States. Moderator Jaspal Singh, MD, MHA, MHS, interviews prominent women making waves in their field and breaking the glass ceiling. Listen in to gain insight on the leadership lessons learned.
Episode 4: Moderator Jaspal Singh, MD, MHA, MHS, interviews Brenda Pun, DNP, RN, and Joanna Stollings, PharmD, BCPS, BCCCP, about intensive care unit liberation; the management of patients with COVID-19 and pain, agitation, and delirium; and their lessons about being women leaders in critical care.
- ICU Liberation Course. Society of Critical Care Medicine. https://www.sccm.org/ICULiberation/Home
- Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018;46(9):e825-e873. https://doi.org/10.1097/ccm.0000000000003299
Jaspal Singh, MD, MHA, MHS, is medical director of pulmonary oncology and critical care education, as well as a professor of medicine, at Atrium Health in Charlotte, North Carolina.
Brenda T. Pun, DNP, RN, is the director of the Data Quality, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt University Medical Center in Nashville, Tennessee.
Joanna L. Stollings, PharmD, BCPS, BCCCP, is a clinical pharmacy specialist in the Medical Intensive Care Unit at Vanderbilt University Medical Center in Nashville, Tennessee.
Jaspal Singh: Welcome, everybody, to the next episode of Critical Care Women Leaders in the Consultant360 podcast series. I'm Jaspal Singh, your host. I want to introduce another 2 rock stars: Dr Joanna Stollings and Dr Brenda Pun.
Brenda Pun: Good morning doing well.
Jaspal Singh: Good. Well, thank you for joining us today. If you don't mind, quickly introduce yourselves and the work that you're doing.
Joanna Stollings: Yes, Jaspal. Thanks for having us. We're super excited to do this. I’m Joanna Stollings. I'm the medical ICU pharmacist at Vanderbilt. I also work in our post-ICU Recovery Center, and I work with the critical illness brain dysfunction survivorship group as well. And then—you know this very well—I'm the immediate past cochair with you for that, for the Society of Critical Care Medicine (SCCM) ICU Liberation Committee.
Jaspal Singh: Fantastic. That's awesome background, and obviously, this is right up your alley. So next is Brenda Pun.
Brenda Pun: Thanks again for having me as well. This is so exciting to be on here with Joanna. So, I'm just glad to be doing that with her.
My name, again, and Brenda Pun, and I am a nurse. I am the Director of Data Quality with that Critical Illness Brain Dysfunction Survivorship Center that Joanna mentioned at Vanderbilt University. We've been doing research around patients in the ICU for the past 20 years. That research really focuses on the 3 areas of critical illness. A lot of that has to do with delirium and sedation in the ICU. Brain dysfunction: again, looking at delirium in the hospital and then the long-term cognitive stuff that our patients face. And then survivorship; how can we improve the best trajectory as possible?
I also work with some SCCM committees as well and dabble in a lot of other little things here and there.
Jaspal Singh: That’s an amazing background, obviously from both our speakers. You talked about this Brain Dysfunction Center and the research that you're doing. Give us a little bit more of a preview about some of the key findings that you're discovering, especially as we wrestle with COVID-19.
I don't know, I'm just going to throw it out there as an intensivist—I have a really hard time managing the pain, agitation, delirium. I think we've finally embedded the guidelines, finally looked at all these principles, finally thought we had things engineered, and then comes along COVID-19, and I feel like I don't know anything in this space anymore. And I'm really having a hard time managing. Tell us about your research and how to help clinicians, like myself and our listeners, about managing these issues based on your research.
Brenda Pun: Sure, I'll jump in here first. We just wrapped up and published a paper on a study called COVID-D. So, think delirium, COVID-19 and delirium. That's the question we wanted to answer: “What is delirium like in these patients? Is it different? And does it have different risk factors?”
What we found in these over 2000 patients from 14 countries—69 different sites worked with us around the world—was that the acute brain dysfunction is quite a bit different. This was from the March/April period of 2020. And so, some of that could have changed by now, but what I hear and see, it seems that a lot of it hasn't changed so much.
We saw that patients had a median of 11 days of coma, and another 3 days of delirium. So, think of a 2-week block of their brain being checked out, either for coma or delirium. Normally, in non-COVID-19 settings, it’s less than a week that we see patients between these 2 brain dysfunction states.
When we looked at risk factors—we looked at all the things that are traditional risk factors for delirium—we listed things that we thought might be unique in COVID-19, which were the types of sedatives that we were using and the amount, duration, as well as looking at the presence or absence of family. For all of us, that’s been a really big difference. What we found were some of the classic risk factors: how old you were and how sick you were. Different markers for that severity of illness indicated that you were more likely to have delirium.
The real take homes were—the 2 big modifiable risk factors—were the use of benzodiazepines, which we've known that for a long time, but in this study, 64% of the patients got benzodiazepines those for a median of 7 days, which is a big change from what our practice has been. In January 2020, most of these ICUs didn't use benzodiazepines for many patients, let alone for a week when they were using them.
And so, benzodiazepines were a risk factor for the development of delirium in these patients, just like they are outside of COVID-19 patients. The presence of family, either in person or virtual, actually protected the patients from the development of delirium, so it reduced the risk of developing delirium.
Those are 2 big take-home messages that we found from the study to apply to folks at the bedside. If you have the choice, don't use the benzodiazepines. Stick with what we know works, so that A to F bundle, and choose wisely not to use the benzodiazepines. In whatever creative ways you can, get family interacting with these patients. Whether that's in person through a glass or through a virtual interaction, it matters.
I would say it also matters for staff, because that's a really big win with both your staff resiliency as well as your patient outcomes. Joanna, any other thoughts from your perspective in the unit?
Joanna Stollings: I've been working in the COVID-19 ICU, which we created specifically for this. It’s a 37-bed unit, and then our medical ICU, which is 35 beds, in which there's a number of COVID-19 patients every day since this started.
I think Brenda's hit the nail on the head. We've tried our best to not use benzodiazepines in these patients, but unfortunately, they do require deep sedation. So, we're not able to use dexmedetomidine quite often. Then we end up having patients on propofol for a number of days. Due to super-high triglycerides or even high CK levels and putting them at too-high risk for propofol infusion syndrome, we've had to change some of these patients to benzodiazepines. We've all been frustrated by it, but there's just honestly not been another option.
With regards to the family part that you highlighted, it was very, very, very sad for not only the patients, their family members, but also the staff, honestly, to not be able to have the family there in person the few months. It was extremely hard, like unspeakably hard.
Clinicians were spending a ton of time on the phone every day, trying to communicate as good as they could with family members and tell family members, if possible, interact with the patients. It was just very, very hard. There were multiple scenarios where patients and family members had to say goodbye to each other via iPad.
There was a story that was published in the Vanderbilt Reporter where a nurse who stood by the bed and held an iPad over the bed for hours to let the patient and the family say goodbye. We, within the last 5 or 6 months have implemented a program here, where patients get to see their family members. Family members can come in between the hours of 1:00 and 3:00 every day. They sit outside the doors, then they can use an iPad, or they can use an iPhone or something, to communicate with the patient. I think that's been tremendously helpful for everyone involved.
With the family members being here in person, that just makes it much easier for the for the staff to be able to communicate about the patient's current status. I'm sure Jaspal could talk about this too; I think it really helps the family to see if a patient may need more toward palliative care. To be able to see that in person vs somebody just tell you about it on the phone, really, I think makes a difference when people are trying to make decisions with regards to goals of care.
Jaspal Singh: Yeah, I think you both bring up some really critical points, and I guess I'm as guilty as the next intensivist. I think a lot of us end up struggling with—one thing we didn't talk about here—ventilator dyssynchrony and the severity of respiratory failure. It's something that's just mind boggling.
Let’s step back a little bit. We had this whole movement of the ICU liberation that both of you have been leading intensely and done a ton of great research. We know it works. We kind of had things down. And then you end up with this illness that just has had some challenges. One of the hardest challenges I have is balancing the ventilator asynchrony respiratory failure, the prolonged nature of this beast, and then trying to figure out, “Am I focusing on analgesia first? How deeply? Then sedation? Then what strategy?”
We talked a little bit about it before, but talk a little more about analgesia, for Joanna. Then, Brenda, piggyback on the delirium from a nursing perspective. What are you seeing and experiencing? What are nurses telling you? Things that are non-pharmacologic that work. So, Joanna, the pharmacology of analgesia. And then, Brenda, the nonpharmacological delirium aspect.
Joanna Stollings: Yeah, I think one of the biggest take-home points that I always like to talk about when I'm thinking about this is that people forget all the neuropathic symptoms that patients can have with this. And so, I'm in the MICU. I mean, it's not like we rarely put a lot of people on gabapentin or pregabalin. And I feel like we have done more that in these patients, just to help treat their pain. And so, that’s one big thing.
The acetaminophen thing has been tricky, because the whole, “Are you masking fever?” vs “We're trying to do multimodal analgesia,” and put that in the background. There was some controversy at first about whether or not you could use ibuprofen in these patients. We are still using quite a number of opiates in these patients for sure. Fentanyl is our go-to unless they're on ECMO and then we’ll use hydromorphone.
This comes into play when we talk about sedation, too. I think one of the biggest challenges is because we do have so many patients, we have tons of travel nurses. We have tons of nurses from every ICU in the hospital who maybe aren't used to using things like the CPOT (the critical care pain observational tool). So, I've taught numerous nurses how to do that, whether it be a traveler or someone who's not as used to doing that. I’ve started these trainings because we do have to still assess these patients to determine whether they're in pain; we don't want to treat them if we don't have to, because that can be deliriogenic.
The other thing, honestly, is these patients, because they are on so many opiates, I feel like I'm like the bowel regimen police every day, which sounds ridiculous. But they're on the most intensive bowel regimens I've ever seen in my life. So, we've definitely had to get pretty creative in that department. It sounds corny, but it's something that we make sure we don't want to forget as well.
Jaspal Singh: That's very helpful. What I heard you say is think about opioids; if on ECMO, for example, switch to hydromorphone or fentanyl, and then think about the neuropathic pain like gabapentin or pregabalin to minimize them. But if they're going to be on an opiate, especially prolonged, think about bowel regimens, and be vigilant about that aspect.
Perfect. That's very helpful. Brenda, what do you think from the nursing perspective on the delirium piece?
Brenda Pun: Well, I definitely want to underscore that family portion, that being creative and thinking about having a plan. Did your hospital go to complete restriction of all visitations? If you have partial restriction, you can come up with creative ways, like doing it how Joanna explained in the COVID-positive patient rooms—having the family member right outside the door.
Our goal isn't just survival, but it is really is thriving past the ICU and past discharge, and when they talk about their time in the ICU, they often talk about this mixture of time where there was a lot of confusion, they may have had these dreamlike scenarios, but they typically will always say, “But when my husband showed up…” So, the family member becomes a north star of sorts for the patient and certainly for the staff.
It's a helpful North Star to connect us to the patient, but it helps to be this connector for the patients. “When I saw them, I knew that some of this crazy thinking I was having wasn't really right. Even if it was, they were on my team. These other people, I'm not sure they're on my team, but I know that my husband is on my team or my daughter is on my team. And I know that I'm going to be okay as long as they're here.” Or “When I see them, I'm being reminded and that sort of brings me back to that reality filter.”
So, whatever method of doing that creatively outside of our norm to get them there, to let the patient sense and see that they’re there in whatever way, is really important. I think just leveraging the creativity of critical care nurses and saying, “What could you do? Let us get you those tools to do this.”
And then I think that, as much as possible, think about the things that we already know. So, you might for a season need this really deep sedation but not to make that the habit. It's the daily questioning of, “How light can they be? Can I lighten this today?” We do that with daily wakening trials, and there's other ways to do that, but that daily saying, “Is this where they need to be today?”
I think that that helps to undo some of the habit forming and the default of getting stuck. And figure out a teammate who can be the one who asks that question every day. It might be the bedside nurse; it might be the pharmacist that’s on rounds every day. But it’s really important to have that steady voice of asking, “Do we need this today? Are there any changes that we can make in this today?”
I think that that helps to get us lighter, because I think it is the sedatives that are our biggest culprits right now. The longer and the deeper they’re in the sedation, the more long-term effects that we're going to see from that.
Jaspal Singh: That's fascinating. That's fantastic work. So, we covered a lot of ground. You also give us some lessons about things that we're learning, things that you've learned about how to manage now that we're seeing a massive surge. Some of us haven't even seen our peak from the holiday season yet. So, we're about to get hit again with additional cases. By the time this podcast is released, most of us will be in our peaks by then and based on the current metrics.
So, lessons that we've learned. Are there other take-home points that you want to bring home?
Brenda Pun: I think that, for many of us, it's really taking a step back and making the best decisions that you can in your current environment but not letting your current environment become the default. I think that that's where that dance of flexibility and going back to what you know is right and best for your patients.
In giving the grace, I think that comes with giving a lot of grace to our teams and ourselves that you may not be able—in a third situation or in a drug shortage situation or in a really difficult patient situation or whatever might be happening—to make the best decision in that situation. But when the situation changes, be sure to adjust your decision-making as the situation changes.
Give yourself that grace. “Ugh, I don't want to treat like this, but this my best choice right now.” I think that's where we see a lot of the fatigue and burnout that's happening with our staff and, nurses not being able to have family there. It’s just like what Joanna was talking about. It’s really hard for us. It’s just making sure that things don't become habit.
When given the choice, choose what you know to be the best possible options and then adjust as your circumstance calls for you to adjust. That's just really a big take-home that I want to give practitioners who are at the bedside, because it's a hard place to be.
You need that grace for yourself and in your care, but you also need that accountability to say I'm not going to make this my new norm. And all these new nurses were training to be sudden ICU nurses. We don't want them to think this is the norm; this is not how we're going to manage these patients every day.
Jaspal Singh: So, some grace, some flexibility, and I hear you say compassion for the whole team and for everybody around and just being there for them, especially if many of the people are younger, less experienced, especially as we hit these surges. So, I think that's great advice. Joanna, any particular lessons you want to share with our audience?
Joanna Stollings: Honestly, I think the biggest lesson I've learned more than anything is teamwork. One of the teams that I am on currently is the MICU, team D. I've worked with people from ophthalmology. I've worked with orthopedic residents. I’ve worked with OBGYN residents. I’ve worked with general surgery residents.
I mean, you name it, I have worked with them, and they are quite often like new interns who have just started and then they got thrown into the COVID-19 ICU. So, like Brenda was saying, they're not even used to a normal ICU experience, let alone this, which is extreme. I think the really cool thing I've learned about it is that everybody brings something different to the table.
We had a dermatology resident one day who diagnosed enoxaparin-induced skin necrosis, which me and my medical director didn't even know existed and had never even seen, which is crazy.
We had an ENT resident who helped the other COVID-19 team that is primarily nurse practitioner-led, and it helped them put in a really difficult Dobhoff tube that they didn't even have to get a consult that they would have gotten because they had somebody there to help them. So, I think that's one of the biggest things I’ve learned for sure.
Like I already mentioned, there's all these different nurses and respiratory therapists who don't normally work there, too, who have come in and, like Brenda said, just being really patient and just not being like, “Oh, well. Let's just throw ICU liberation out the window, because this isn't going to happen.” Really just taking the time and having patience to sit down with these people and to explain, “Okay, this is this the CPOT. This is the RASS. This is how you do a CAM-ICU.” Just so that they understand it so that we really can provide the best care for these patients.
It is a little more difficult, like when you go on rounds, just because if the nurse is in the room, then it might be difficult to get a patient report. I'm still trying to time it when we’re on multidiscipline rounds so that we can get the best information from the nurse. We even had creative things with regard to getting the best information. For instance, we had somebody write down all the different things, hold it up to the window, whatever we need to do to get the best information.
We can't just walk by and be like, “Okay, I don't know what their CAM-ICU is. I don't know what the RASS is.” You can't do that—like Brenda said—absolutely every day. We're talking about, “Hey, what is their goal RASS? What’s their actual RASS? How can we make these match?”
If they're on a paralytic, make sure that we talked about turning that off like every doggone day, because we do not want people to be on that any longer than they have to be. Make sure we're checking appropriate labs with sedation and such to show that we don't have them on benzodiazepines and things, if that's not what we have to do.
Jaspal Singh: That's great feedback. Building on what Brenda was saying earlier, the idea of teamwork but now with the clinical lens, making sure you go back to the basics. Also, recognize that other team members who aren't traditionally in the ICU may have a lot to add, potentially clinically, from skill sets to various ways of looking at things and doing things.
But it comes at a trade-off of additional work potentially created in terms of orienting them back to the basics but that the basics work and that the stuff that we've already built on—you both helped to really build that foundation of the ICU liberation work—works. The data suggests it, it continues to suggest it probably will in the “long COVID world,” as we call it.
I think you've set up very nicely. That’s also a nice segue into the last question I have: a lot of leadership skills and a lot of awareness of how to work with others and how to do things better. And I think this podcast challenges every aspect of your personal life and personal challenges and your own leadership skills are tested.
What are some of the personal challenges in this pandemic that you and others are facing, both professionally and at home? You can elaborate that a little bit. And for our listeners—many of them are women in the series—are there unique aspects of the story that you want to share with others? And you can be as personal as you want.
Brenda Pun: Sure. For me, one of the hard parts with the pandemic is that my children have been out of school this entire time. So, virtually, they have not set foot in a school or an in-person classroom since last March before their spring break.
So, there's always that constant need. I, fortunately, have middle schoolers. And so, they're able to be independent, but it has caused a big shift in my daily work schedule, the way that we run things, that sort of thing. And initially, when COVID-19 was really starting to come to the United States, everything was starting to shut down. My workload actually quadrupled, because we were launching this big study, this international study.
We have an amazing team that has a weekly meeting, and part of that is a, “How are you feeling?” discussion. I remember in one meeting saying, “I'm just jealous. I'm so jealous of these other people who have nothing to do right now, because I have 3 times as much stuff to do.” And it was just trying to figure out how to fit that in when there were more needs for me at home and get that done.
So, I felt like everything that I did for the first 6 months of COVID-19, whether that's a calendar or whatever that means, it really was fitting every single minute in and that was a big challenge. I still wrestle with grieving the loss of all the normal—you know, eating in restaurants and going on vacation. So, it certainly came with a lot of those types of emotions on the background of a very busy schedule.
Jaspal Singh: That’s fantastic. That’s good to share with our audience. It's a tough one. I don’t know if there’s a magical solution. My wife does a lot, so she's been taking the brunt of a lot of this stuff. I owe her a ton. Joanna, what are your challenges?
Joanna Stollings: I'm single, and I live alone. COVID-19 has brought me some different charges, because my personality is very extroverted. I'm spending a lot more time than I normally do at work, obviously, but it's been hard, because when I go home, it's like there I am!
I've never spent a lot of time at my house before. I'm very active. I like to go run in groups, and I like to travel, and I haven't been able to do that. Honestly, it's been really lonely in a lot of ways. That’s been hard on me because I would have done some of these other things. Thankfully, I can still run. I can still run with maybe a friend or 2, but I would have done some these other things that I can't do to help relieve some of this stress from all the work. I think that's been really hard.
The other thing, which I honestly had never even thought about until COVID-19 happened, is that most people do not know that clinical pharmacists exist. We're kind of like that extra safety net out there that nobody knows about. Maybe, I would say, 5% of the population knows what clinical pharmacists do. If you don't work in a hospital, you probably do not realize that. Usually when I meet people, they’re like, “You're a pharmacist. You work in this retail store or this retail store.”
I don't think it's ever bothered me before, but with COVID-19, I've been working like 50 to 60 hours a week and it's just been very, very stressful. I feel like it's been hard for me to express that to people at points, because nobody understood exactly what my job was, exactly what that entailed every day.
People always think about physicians or nurses as being essential workers, but they forget that there's a lot of other people who are very important to patients’ care who aren't necessarily remembered. I think that was hard, too, trying to figure out how to deal with the stress of that, too.
Jaspal Singh: Thank you for saying that. As you were talking, I was reflecting back to when the pandemic first hit and we shut down our team-based rounds to preserve PPE, for example. You forget how much everybody does, not just the physicians, the nurses.
At least, think God, the respiratory therapists (RTs) got some love this year. They weren't obviously getting a lot of love, either. But then pharmacists; our pharmacists weren’t around. They’re on Zoom or Skype or something of that nature, on Teams. It didn't feel like we quite understood how to manage these folks. And now that we have multiple ECMO circuits going, I need my pharmacist there to really help me understand what I’m delivering. Is it even in the system anymore? Or is it being siphoned off? I don't know about these things, because I don't think about this stuff.
But you bring up very important point about the role that the team plays and the skills that you need to balance all that. But for one, we want to thank you for all that you do—both of you for all that you do—for the CERT, for the field, for the patients, for the communities that you serve, and especially for the research.
I look forward to what comes out of Vanderbilt’s Brain Dysfunction Center, because we as a society will see a whole bunch of people who survived COVID-19. There will be some sequalae, and we want to see what you all contribute. We're looking forward to understanding articles and I think you're going to make a huge impact in people, whether it’s recognized or not immediately. I’m, for one, grateful.
So, I want to thank you both for being on here today. Again, I'm Jaspal Singh, your host. With me today is Dr Brenda Pun and Dr Joanna Stollings from Vanderbilt University. I want to thank you both for all the work that you do.
Joanna Stollings: Thank you, Jaspal.
Brenda Pun: Thank you for having us.