“What if I told you that we knew, through an evidence-based approach, how to reduce death, reduce length of [hospital] stay, reduce cost of care — and we weren’t using It?” Intensive care unit (ICU) expert Wes Ely, MD, MPH, raised that question at Learn Serve Lead 2022: The AAMC Annual Meeting on Nov. 14 in Nashville, Tennessee.
Ely, a professor of critical care medicine at Vanderbilt University Medical Center, went on to pose an even more painful question: What if we had started those crucial steps and then stopped?
Ely was referring to extensive research proving that certain ICU practices had long caused harm to patients, including brain-damaging delirium. As he described in his 2022 book, Every Deep-Drawn Breath, he and others eventually developed, implemented, and proved the efficacy of new approaches that were adopted at thousands of hospitals worldwide.
But then COVID-19 struck.
“[Previously], we had seen rates of delirium of 70% to 80%, but we tore that down,” he said. “And then COVID hit, and the whole thing skyrocketed back to 80%.”
In a session moderated by Khalilah Gates, MD, a pulmonary and critical care specialist at Northwestern Medicine, Ely outlined decades of research proving that previous standards of ICU care often created serious new problems for those whose lives it saved.
The approach Ely helped establish includes using less sedation — which previously had been considered essential for keeping patients calm — and weaning patients off ventilators more quickly. Such changes, now known as the ABCDEF bundle, allowed patients to achieve greater mobility, gain mental clarity, and renew the personal connections vital to healing.
During COVID-19, though, an influx of patients and the challenges posted by a previously unknown virus drove ICUs to revert to longer sedation and immobilization.
“We were scared, we didn’t have vaccines, we didn’t have [personal protective equipment].” But measures like keeping patients from their families was wrong, Ely said. “I never want to practice medicine that way again.”
He noted that restoring better practices is not about distributing protocols on a piece of paper. Instead, it involves a doctor and nurse working together at the bedside to apply the appropriate steps and monitor their effects each day. “If we take it slow and make it patient-centered and don’t try to get at the whole program [at once], we can change the culture.”
But to truly achieve appropriate ICU treatment, honoring the entirety of the patient — mind, body, and spirit — is crucial, Ely emphasized.
“Let’s commit ourselves to re-humanization,” he said. “Let’s pay attention to things like putting touch before technology.”
In one powerful example of such an approach, Ely called to the stage the wife of a former ICU patient whose bedside wedding Ely facilitated and who spoke of her enduring gratitude that “they made us a family.” Ely added: “The power of love is greater than science.”
In a discussion about medical education, Ely urged an approach that merges science and humanism. “These two things are siblings. They go together. You can’t be a doctor with science alone.” The goal, he said, is to “find the person in the patient.”
Several months ago, Ely spoke with AAMCNews about his innovative work, the role of humanism in medicine, and how he’s managed to persevere despite numerous obstacles in his path.
You had some painful moments when you realized you were causing patients harm. Can you share one such story?
Teresa Martin was one of my first patients. The 28-year-old came to the Wake Forest Medical Center in Winston-Salem, North Carolina, after a suicide attempt that she later regretted. Teresa had lost consciousness, and several organs were in different stages of failing. We put her on a ventilator, immobilized her, and heavily sedated her. After several harrowing weeks, we were thrilled when she could leave the ICU.
A couple of months later, she came back to see me in the clinic. I thought it would be a high-five moment, but she came back in a wheelchair. She looked like an old woman. She couldn't go to the bathroom by herself. She couldn’t think clearly.
I just stared in the mirror and thought, ‘What did I do to her?’ I was a danger in her life. That really started the process of me kind of carrying around shame and guilt for many years, and then trying to unpack it.
What is ICU delirium, and why is it dangerous?
ICU delirium is the outward manifestation of ongoing brain injury. The person can’t think clearly, and they can’t pay attention.
ICU delirium can be caused by blood clots that prevent brain cells from getting the necessary oxygen. But it also can be caused by such ICU factors as sedating medications, strong painkillers, isolation, and unfamiliar surroundings.
Every additional day of delirium is a predictor of a 10% increased risk of death and a 35% increased risk of brain dysfunction. If you do the math, with three days, you’re one-third more likely to die and you’re practically assured to have long-term brain problems.
ICU stays can cause other life-altering harms. What are some of those, and how do they happen?
People come into the ICU with one problem, but then they acquire a whole new constellation of problems — PICS — that includes brain, muscle, and nerve problems. PICS causes tremendous disability.
When somebody comes into the ICU, the old way of caring for people was to tie them down and immobilize them. We thought we were helping them because it prevented them from pulling out their lines and tubes — but we grossly overdid it.
For example, disuse of muscles causes atrophy — and when you’re not healthy, the atrophy occurs way faster. People can lose 10% to 25% of their muscle mass in just four or five days. It’s shocking.
People may also leave with PTSD and other mental health issues. Part of it has to do with hallucinations. One patient believed he was in a game show every night, with people in front of him with bags on their heads and he had to shoot one of them. And every night when they took the bag off the person's head, it was always his daughter.
Part of what we have to do is help [ICU survivors] make sense out of their experience. And we need to say, ‘We won’t abandon you. We’ll accompany you down this road.’
You helped revolutionize ICU treatment. One dramatic step was to move away from heavily sedating patients. How did that help?
Less sedation is better for several reasons. One is that when you sedate somebody, they enter a deep coma. Their brain cells go into kind of a state of suspended animation that injures or kills the cells.
Also, although you look like you’re asleep in a coma, the sedation actually prevents healthy sleep. You go into a prolonged state of sleep deprivation, which is very dangerous for the body.
Sedation also fakes us out by making patients look sicker. If I wake patients up and let them be with their families, it’s amazing how much better they look, which affects other medical decisions staff make.
You suggested a number of other bold moves as well. Can you give some examples?
We created a safety bundle of six steps, with the abbreviation ABCDEF.
The bundle says to manage the pain without overmedicating — that’s A for analgesia. Get rid of the ventilator and the sedation as soon as possible — that’s B for both, a daily attempt to remove the sedatives and the breathing machine. There’s C for choice of analgesia and sedation. D is for treating delirium correctly, which includes environmental steps like using light to match day/night cycles. E is for early mobility. We wake you up and get you walking, sometimes with your respirator trailing behind you. And there’s F, having the family present and engaged.
We’ve studied this in over 30,000 people, and the higher the compliance with the bundle steps, the better the survival rates, the shorter the stays, the lower the cost, and the more likely you are to go back to your home instead of to a rehab facility.
We’ve translated this bundle into 40 languages, and it’s now used all over the world.
How hard was it to try to change ICU culture?
Oh, my gosh, it was terrible. We would come into an ICU and get people to use the new approach. But then the staff would change, and we’d come back a month later and they’d be right back to where they were before. It was maddening.
I knew that the only way to make this change would be thorough research. Doctors and nurses are scientists. So, we had to study this in very intense detail and publish the results in the highest journals, which we did.
Along the way, a lot of people yelled at us, saying that we were being unethical because they thought waking people up would be physically and emotionally unsettling to them. A lot of people called me into their office and said, ‘What are you doing? This is going to be a career-ender.’
How did the COVID-19 pandemic set back advances in ICU care?
Before COVID-19, around 90% of ICUs in the United States used our bundle. Not all of them complied with 100% of it, but they incorporated its major components. In one study of ICUs in 40 countries, staff were about 70% to 80% compliant with it, which is very high for clinical protocols. Then we measured it during COVID both in the U.S. and abroad, and we found they had dropped down to 10% to 20% compliance.
Isolating patients, restricting visitors, longer sedation, and more immobilization came back. Early in the pandemic, those were for legitimate reasons, including that we didn’t understand the virus well yet, we needed to manage a huge influx of patients, and we needed to protect people. But as soon as the vaccines were available and we had enough [personal protective equipment], they didn’t make sense.
Unfortunately, hospitals sometimes just kept those policies in place, and there was a tremendous amount of undue suffering. We’ve got a long way to go to rebuild now.
What has helped you keep going despite major obstacles?
Patients are the drivers for me — their bravery, the gift of their stories. I’m on a mission for them. I’m donating all the net proceeds from Every Deep-Drawn Breath to an endowment at Vanderbilt that will leverage the talents of social workers to help ICU survivors all over the country and world pick up the pieces of their lives.
What I tried to bring out in the book is that you can’t take care of people with science alone. You’ve also got to pay attention to their minds and their spirits.
Most of what I have learned over the past 25 years is about bringing humanism to the bedside in all that we do — bringing care that is full of compassion and empathy. I’m still growing in this, and I have a long way to go. We must teach these traits to medical and nursing students as part of their curriculum.
I took the title Every Deep-Drawn Breath from Steinbeck’s East of Eden. In that book, Steinbeck says there is something so gorgeous and unique about the human condition, if we respect the dignity of who people are.
I found that when people are sedated, immobilized, and depersonalized in the ICU, it masks their human dignity. It masks who they are as people.
This conversation has been edited for brevity and clarity. Dr. Ely can be found on Twitter and TikTok at @WesElyMD.
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