Innovation SOARs in the CTICU | Interview with Dr. Mikita FuchitaFeb 1, 2023
The mission of the Institute for Healthcare Quality, Safety & Efficiency is to ensure that every patient receives the highest quality of care. One of the ways we do that is by training and building teams that are capable not only of deploying interventions but sustaining them to improve outcomes for patients. A team from the Cardiothoracic Intensive Care Unit that completed the IHQSE Improvement Academy recently launched their SOAR (Sedation Off, Awake, Rehabilitate) initiative which is aimed at weaning patients off deep sedation sooner to mitigate adverse outcomes related to prolonged sedation periods. The intervention allowed the team to mobilize one of its most critical patients on ECMO. We spoke with Dr. Mikita Fuchita, one of the doctors spearheading this initiative to learn more about the SOAR initiative and its impact.
Dr. Fuchita, can you tell us about what goes on in the CTICU and the team that helped build and implement the SOAR intervention?
The Cardiothoracic ICU team takes care of one of the sickest patients in the hospital—including those who are on extracorporeal membrane oxygenation (ECMO), the ultimate life-support device. The team comprises nurses, nursing assistants, intensivists, cardiothoracic surgeons, advanced care providers, fellows, residents, a pharmacist, a nutritionist, respiratory therapists, physical and occupational therapists, speech-language pathologists, and a social worker. It’s truly a multidisciplinary team working towards a common goal: to provide life-saving interventions and to preserve the quality of life of our patients.
Most of our patients have critical cardiac conditions that require surgical interventions. Patients with severe coronary artery disease, congestive heart failure, severe valve disease, and aneurysm of the aorta, to name a few. Some patients require mechanical circulatory support such as an intra-aortic balloon pump, left ventricular assist device (LVAD), and ECMO. We also take care of patients with complex thoracic diseases that require major surgery, such as pneumonectomy and tracheal resections. And lastly, we take care of patients immediately after heart and lung transplantations in collaboration with the transplant team.
Explain why sedation can be bad for patients.
We noticed during the COVID-19 pandemic that a lot of our mechanically ventilated patients were receiving deep sedation and being left immobile in bed. Over 20 years of research have demonstrated that deep sedation and immobility not only increase mortality but also traumatize our patients beyond their ICU stay. About half of ICU survivors develop a condition now known as post-intensive care syndrome, or PICS. Patients with PICS suffer from newly acquired anxiety, depression, post-traumatic stress disorders, dementia, and severe physical impairments. Many of these conditions are related to sedation, which can exacerbate delirium, an acute brain dysfunction associated with nightmares and intrusive hallucinations.
Where did the idea for a sedation weaning protocol come from?
When I was an ICU fellow in early 2021, I stumbled upon a podcast that changed the course of my career. This podcast talked about an ICU in Salt Lake City that used no sedation for their intubated patients. This ICU published a landmark study in Critical Care Medicine in 2007 (PMID: 17133183), describing the feasibility and safety of mobilizing patients (that is, walking them in the ICU) with breathing tubes. This study attracted the interest of world leaders in critical care medicine, and sedation minimization and early mobilization are now considered some of the pillars of evidence-based practice for mechanically ventilated patients in the ICU. Yet, many ICUs nationwide still struggle to implement sedation minimization likely due to various cultural and practical barriers.
I invited the podcast host, Kali Dayton, for a lecture in August 2021. After the lecture, Caitlin Blaine (APP), Alexis Keyworth (APP), and Blake Primi (fellow), reached out to me, saying that we should try the same approach in our Cardiothoracic ICU. This is how the SOAR project began. We grew into a multidisciplinary team by January 2022, consisting of two charge nurses, a nursing educator, two respiratory therapists, two physical therapists, and an ICU pharmacist, in addition to the original four members. That is when we enrolled in the IHQSE Improvement Academy and received an IHQSE CEPS (Clinical Effectiveness and Patient Safety) grant to fully operationalize our project.
What are some of the barriers to sedation minimization?
We conducted interviews, focus groups, and online surveys of over 100 clinicians that routinely work in the Cardiothoracic ICU to understand why we rely on sedation when taking care of our mechanically ventilated patients—when 20 years of research suggests a clear harm. Among many barriers to sedation minimization, we learned that many of our ICU staff believed that sedation was a form of compassionate care and helped alleviate the psychological stress of mechanically ventilated patients. The survey also indicated that more than 80% preferred to be sedated if they were mechanically ventilated with a breathing tube. Based on these results, our team realized that to change our sedation practice from deep to minimal or no sedation, we needed to change our narratives surrounding sedation.
This intervention recently produced some amazing results for your patients, can you tell us about these success stories?
In late September, I received an email from our physical therapist, who reported that she and two bedside nurses were able to mobilize a patient with a femoral ECMO. The patient’s name is Chenille. At only 19 years old, she suffered from acute respiratory failure and required ECMO support to maintain her blood oxygenation. Despite the anxiety attacks Chenille experienced, the nursing staff got her out of deep sedation and walked her around the ICU.
Bill is another patient that thrived with no sedation while being intubated for acute respiratory distress disorder. Coincidentally, day 2 of mechanical ventilation was the wedding anniversary of him and his wife. Because Bill was awake, alert, and delirium-free, they were able to celebrate their anniversary together. He also ambulated in the hallway with a breathing tube. Later, he described that “I was surprised at myself (that I could walk), but also proud of myself” for ambulating while on mechanical ventilation and appreciated the ICU team for encouraging him and for pushing his limit.
What were the major challenges to mobilizing a patient like Chenille?
At our hospital, any femoral ECMO cannula was considered a contraindication to patient mobilization beyond bed rest. We worried that bending the groin would impede the ECMO blood flow, cause drops in blood pressure and/or oxygenation, and risk patient safety. But emerging literature support that with meticulous safety checks and teamwork, even patients that have support devices (such as ECMO and intra-aortic balloon pump) going through the groins can safely mobilize.
Why is mobilization so important to a patient like Chenille?
Numerous articles published in high-impact journals show that early mobilization of patients in the ICU reduces mortality, delirium, mechanical ventilation time, hospital length of stay, and long-term consequences such as anxiety, depression, post-traumatic stress disorder, and cognitive and physical impairments. Simply put, it is a life-saving intervention that also preserves patients’ quality of life beyond their ICU stays.
Patients often describe mobilization as therapeutic in various ways. It lifts their spirit. It gives them hope. It is a tangible step forward that brings them closer to home. Chenille’s smile—while sitting at the edge of the bed with femoral ECMO—told it all.