Episode 180: Leading the ABCDEF Bundle in Bangledash
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This is the Walking Home from the ICU podcast. I'm Kaylee Dayton, a nurse practitioner and ICU consultant. I help teams create awake and walking ICUs through evidence-based sedation and mobility practices. By hearing from survivors, clinicians, and researchers, we'll explore how to give ICU patients the best chance to walk out of the ICU and go home to survive and thrive. Welcome to the ICU revolution.

Since talking about the ABCDEF bundle on this podcast and online since 2020, I have constantly received comments such as, quote, this is only happening in academic hospitals, or you're just doing this for the clicks. This isn't actually being done anywhere, or there must be one-to-one nursing ratios and tons of ancillary staff there, or hospitals can't afford to provide the staffing and equipment to do this, or this is

This is only possible in the nice first world hospitals. In episode 55, providers from 22 different countries shared their successes with walking into a patient. Most of those countries were not first world. There is almost a greater recognition of the desperate need to prevent delirium and ICU acquired weakness in these countries that do not have the staffing and resources to care for these patients for weeks or months longer than needed.

These countries do not have LTACs and SNFs to send their patients off to. When patients develop these ICU-acquired complications, the ICU teams themselves are left to deal with it

rather than able to shift them off to another facility. It also almost seems like the most educated of clinicians in hospitals are some of the most challenging to educate. When a team feels they've already achieved the highest level of excellence possible, they are less open to ideas and techniques that are new to them.

I am so excited to have our guest for this episode share what can happen even in a low resource country and unit when a humble team fueled by passion and humanity comes together to learn and implement best practices. There is a lot that academic hospitals and first world countries can learn from this incredible team in Bangladesh.

Dr. Jahid Alam, I'm so excited to have you on the podcast. Can you introduce yourself to our listeners? It's my pleasure, Kelly. My name is Mohammad Jahid Alam. I'm working as an associate consultant of Department of Critical Care and Emergency in Apollo Imperial Hospitals in Chiragong, Bangladesh.

Second biggest city of the country. I have been working in my hospitals for the last three and a half years. Before that, I have done my residency program on anesthesiology in another referral hospital, Chirag Medical College. Since then, I have been working in an ICU for three and a half years. Well, I'm thrilled to be connecting on this initiative on awake and walking ICUs all the way in Bangladesh. Tell me about your current ICU. What kind of patients do you have?

And let's get into the staffing ratios and how your team functions. My ICU is a mixed ICU. Though we have been a 65-bedded ICU, all our different surgical, neurological, gynecological, and like this. Though our hospital has been functioning for the last three and a half years, it's a kind of new hospital. We are

We are now functioning on an 11 bedded ICU. In my ICU, 55 to 60 patients in a month. We are a low resource country, so we can't give always the one-to-one stubs in for every patient. One bedded patient, one nurse is not possible actually, not all the time. Because if the patient is ventilated, then one-to-one. If the patient is not ventilated, it's more of a one-to-two or one-to-three. Oh, I see. So it's one nurse, the two bedded patients, or...

When they're not vented, it's one to three. So that's pretty similar to the U.S., if not maybe a little bit more load for the nurses than what we have in the U.S. Look, when in and around my ICU, I have daily five to six patients. So if I want to mobilize every patient, so not every patient in the same body configurations, maybe someone is 40 kilos, someone is 90 kilos, someone is 110 kilos.

and they are very sick. Even if not the patient is ventilated, they are very sick. So when we want to mobilize the patients, we together, doctors and the nursing staff and the respiratory therapists all need to join to mobilize the patients.

Because if we want to mobilize a one 10 kilo patient, so if you think that at least five or six patients need to be engaged with that time. So it's the kinds of practice now in my ICU. Initially, it was very difficult, but for the last one and a half years, at least you can say for the last eight or 10 months, it's become a practice or a habit.

Initially, for mobilizing a patient, when I went to hospitals in the early morning, I need to go there and tell them to mobilize the patients, leave the patient from the bed. And now it's become a practice. Now what I'm seeing that before I reach the hospitals, before I'm going for the rounds to the ICU, the patient has been mobilized, the patient has been seated down in the chairs or CPT has been given, lymph tissue has been given, the patient has been walking.

So it's the practice. It took time to make it a habit, but I'm glad that it's a practice now. That is so exciting. And so you really were the instigator of these changes, correct? Yeah. Was this part of your training or how were you trained to practice critical care medicine and what opened your eyes to this approach?

No, it's actually not in my training. The triggering point was actually when I think that the patient has pneumonia, the patient was in ventilator like, the patient has sepsis. We have done everything. The patient has been improved. The patient has went from the ventilator. The patient's stock has been corrected.

pneumonia has been resolved. So after five or six days, I was seeing that the patient developed the bad sores. So it was the first thing, it was the first thing which triggered me why after doing everything, we have given everything, but the patient has better. Later I came to know that the patient developed the myopathy or neuropathy, ICU-acute weakness.

So after going through those literatures and videos and many of things, then I came to know the ABCDEF bundle. So when I show in my ICO, I have a board in my ICO. So in my board, the bundle has been written ABCDEF. So I have a session of monthly two times in the first of Saturday and the last Saturday of the month.

So in the session, we mainly discussed about the bundle, each component, how we can, it's more often with the nursing staff rather than the doctors. Because what I feel in the ICU, the majority of patients' outcome is fully dependent on the nursing staff. Because they are the persons who are continuously in front of the patients or with the patients.

So it's more often doctors know how to implement this. It's more of the nursing staff who needs to know what can be done, what needs to be done. During the start, it was quite tough, but it's not so easy. And were they scared? I mean, this is a very new thing for them, for you. You're trying to lead something you've never done before.

So that's why I need to put so many videos to them. So I need to tell them even still today I participated with them during the mobilizations. It's not that I'm the consultant, I'm the doctor, I can't lift the patients, I can't touch the patient. I actively participate with them to pull the patients from the bed. Even I sometimes I personally give the CPT to this patient, I personally do the lymphedema to the patients. So when they are seeing that

I am their consultant. I am their boss. I'm doing it. So they now do it patiently. At first, they were forced to do, but it's now become their routine and they're more patient on them now. I love this. I'm just saying physicians take notes. Being a true leader, you brought in the why, you educated, you taught them why.

And then you're teaching them how by actively doing it with them. And this is a new skill set for you as well, but you physically being present and hands on the patient, helping them get up, brings in a lot of comfort for the nurses, for the rest of the staff. It forces them. It's obligated. And the doctor saying we're doing it. The doctor's doing it. They're going to help. They're going to do it. How do you feel like that changed their mindset and their fears about mobilizing patients?

The problem is, the fear is at least what I trained themselves before that, but they need during mobilization of what they can, like a patient in a bed for two days or three days. So suddenly when we lift up the patient, there could be a postural drop, there could be a postural hypertension, there could be some desaturation, there could be some fluctuation in the hemodynamics.

So at first I taught them, I give them what we can anticipate, what difficulties they face. Like initially we face the patient has a hypotension, the patient was in not uttering support. When they leave the patient, front of the patient or leave the patient, there is a postural drop. So I was in front of them in every patient. So when I was there, I was managing the patients. I was telling them, no, don't worry, it will settle down, give some fluids.

don't worry give some oxygenation but don't worry it will settle down so the

They become habituated to what complications might happen and what can be done. So I can share with you an experience. We have mobilized a patient with 130 kilos. The patient was in cardiomyopathy. The patient had an ejection fraction of 27%. The patient had pneumonia and had a failure also. So we mobilized the patient from bed, maybe 15 to 20 meters from the bed. So the patient has a walk and the patient is sitting down in the chair.

Everything was fine. We have a monitor, we have portable monitors. Everything was fine. The patient was talking with us with the nursing staff. And just within a second, the patient had an injury in the chair. So immediately we jumped down and the nursing staff was there. He started the CPR in the chair. So we everyone rushed down to the patient. So we immediately shipped the patient with the nearby bed. We started the CPR and the patient actually reverted and the patient has survived.

So one thing is that you can tell them what can be anticipated and another thing is things happened and you manage. So when you manage the patient then it becomes more easy to manage the patients.

So there is a lot of these small things happen. They manage, they resuscitated. So initially it was a fear. Now it's become a practice that, okay, this can be happen. We'll manage in this way. That's so interesting because an experience like that, where someone rests in the chair, that would be very easy for the rest of the team to say, see, it's unsafe. Let's never do this again. Let's just keep them in bed in a controlled, safe place. So how did this become okay?

we now know what to anticipate. I mean, you couldn't have anticipated that, right? He had no warning signs. That's really tricky. So that is a worst case scenario. Yeah. Yeah. It was actually the worst case and it was the worst experience after mobilizing the patients. So it was the most worst case. Other than this, there has some hypertension, some tachycardia, some deterioration. It can be managed, but

It was a double-sorted experience. After that, nursing has to become afraid of. So later, we manage the patients. So when we manage the patients, so everyone become more confident. They know, okay, it can be happened, but we can manage also. Like you've already lived the worst case scenario. Your team figured it out. Because it takes a lot for us within the team to know that

Everyone knows how to work together in those worst case scenarios. That experience also taught us that to mobilize the patient with ischemic cardiomyopathy with that low ejection fraction, so we need to be more careful. So we thought that, okay, if a patient has a low ejection fraction and the patient has some cardiac issues, so we need to be more careful or we need to be more cautious to mobilize the patient. Because what I figured out that

well we moved the patient 10 to 15 meters from the from his bed so that that 15 to 20 meter walk has done some exhaustion maybe as he has a low ejection fraction could be there was some arrhythmia actually the patient had actually the vt when we immediately shifted the patient from the chair to bed we put the monitors and see that it was dead so it has been managed so these are the experiences there's a little experience

which actually strengthened us. It led to the root cause analysis to look to understanding the physiology of why that happened and leading to more critical thinking in the future. Because every patient is different. Every condition is different. Mobility is like a medication. You have to give the right kind at the right dose, the right timing. But that's, I love that you as a leader didn't say this was an absolute failure. Let's learn from this, celebrate the good and learn from failure.

the things that didn't go right. So now when you come on, your patients are oftentimes already up in a chair. They've already mobilized. But initially you had to go in early in the morning and go patient to patient, nurse to nurse and say, let's do this. And you did it with them. Yeah. This is such prime leadership. Wish more physicians had that engagement with their teams and understanding initially the teams need that kind of security, right?

They need more time to figure out all the logistics of mobilizing patients. But that's when I train teams, I try to explain that's not a long-term plan. You're not always going to need five people.

You could get this down to two or three people, but you have to develop those skills first. It's just like when you're learning how to intubate, put in central lines, you need a mentor with you. It's going to take more time. But as you develop that skill and you become more efficient, you can do it by yourself. You don't need as much time. It's just like any skill we do in the ICU. But I think we don't understand the intricacies of mobility and we just get overwhelmed and give up and we're afraid of it.

But even if you've never done it, you took leadership and you're like,

I've watched these videos. I know it's possible. Together as a team, we can figure this out. And we have to. There was no one in Bangladesh that had ever done this. I think, no. In Bangladesh, what general people think, even what the medical professionals also think, that if a patient is in an ICU for five or six or seven days, they have a bed sore. They will definitely have a bed sore. It's the common thing

thing in everyone's mind. Even I can just share you a case. We have a patient of around 110 kg. So that patient is a female patient. She had bacterial meningitis and septic shock. She was intubated. She has an AKI and she had multiple pulmonary liver dysfunction was also there.

So she's a very well-known person in the society. So she has lots of relatives, even the medical profession, maybe four or five doctors of their family. So every day they tend to ask during our counseling session that is the patient has a bad sore? Is the patient has a bad sore? Is the patient has a bad sore? After five or six days when the patient went from the ventilator, the patient has been seated down in the chair. So we allowed one of their family members who was a doctor.

So when she came to visit to her, immediately she checked his back whether there is a bed sore. So when she didn't see any bed sore, she was so astonished that this patient has seven days in an ICU and she doesn't have a bed sore. So it's quite remarkable. So these kinds of mindsets we have in our society, even within our doctors, that if a patient has five or six days in ICU, they'll definitely have a bed sore.

But in our hospitals in my MSU, the bat-shot rate has been falling down drastically after these mobilizations. So early mobilizations and the everything and the patient even has... Because just going through your previous points, initially when I was in the hospitals, I'm doing it in the early morning mobilizations for only the one time. Now it becomes...

regular that much regular date it is as like is given an N divided three times daily we are giving the mobilization at least three times daily in the morning in the evening and in the nights so it's become initially it was the first time of only one day in the morning now it's become the daily practice ligand three three times in divided dose

So it should be given in the three times and everyone given it in the routine. When you first reached out to me, I'm like, that's what you said is when our ICU, we treat it like an antibiotic, which made my heart sore because

That's the comparison I use when talking about my home ICU, that it was just as important and optional as an antibiotic. And that we too did it at least three times a day. It was just like a conveyor belt. You're going to get morning mobility. Everyone's going to get up afternoon, night. And it was just, unless there was a very valid reason not to. If you've been listening to this podcast, you're likely convinced that sedation and mobility practices in the ICU need to change.

The ICU community is facing incredible difficulty with the trauma from the pandemic, staffing crisis, and burnout. We cannot afford to continue practices that result in poor patient outcomes, more time in the ICU, higher healthcare costs, and greater workload for the ICU team. Yet the prospect of changing decades of beliefs, practices, and culture across all disciplines of the ICU is a daunting task.

How does this transformation start? It can begin with a consultation with me to discuss your team's current practices, barriers, and to formulate a plan to help your ICU become an awake and walking ICU. I help teams master the ABCDEF bundle through education, consulting, simulation training, and bedside support. Let's work together to move your team into the future of evidence-based ICU care. Click the link in the show notes of this episode to find out more.

That kind of culture is hard to imagine. And people just assume that ICU had very different staffing ratios. It must be one-to-one. You must have so many physical and occupational therapists. You must have so many respiratory therapists. They don't, they run very lean, very normal ratios, sometimes subpar. But it's because it's a culture, a skillset. The more you mobilize patients, and you probably have seen this,

The stronger they stay, the easier they are to mobilize, the quicker they are to mobilize, the less risk there is, all of these things. So it has to have an ongoing momentum rather than waiting until day seven to now mobilize them only once a day. It's always going to need a huge army to get them up.

And I'm just my mind is blown by the rates of bed sores here in the States. That's the problem. But we also have fancy beds. We've got strict protocols about turning. We've got quick high level nutrition. And yet still we have bed sores. And so people always think, well, mobility must only happen in academic hospitals where they have so many resources, so much staff.

And the point I try to make is, yes, obviously those things can help. But you have countries like Saudi Arabia, Ireland, where they have one-to-one staffing ratios for the nurses and ICU patients, but they still don't mobilize their patients. You've got to have the culture as well. But in some of these countries where you guys don't have excess resources, you don't have that latest technology.

beds and the new mattresses that you're swapping out every five years, right? You don't necessarily have all the nursing homes and LTACs and you can't afford to have these patients staying in your hospital weeks on end. We can't afford it in the ICU either, but yet somehow we do that. But there's an extra level of necessity to prevent these complications. And so the fact that without all the high tech things that are available to prevent bed sores, you have drastically dropped your hospital acquired pressure injury rate

by early mobility. You don't leave them in bed, they don't develop bed sores. It's amazing. I just want to share another thing. I have a very good friend of my Italian friends. His name is Dr. Luis. Last, maybe two weeks back, he visited Bangladesh due to some research works.

So when I tell them that I'm doing this, the early mobilization things, or this, I have seen him the videos. So he told me that they just send me the videos. I want to show my Italian colleagues in Italy because they don't want to mobilize the patients.

He also acknowledged that you are doing very good things. Because even in Europe, even in my Italian hospitals, early mobilization is still a problem because no one wants to do it. No, I think you guys are a model unit for the rest of the world. You know that you're

Pressure injuries have drastically dropped, but are you tracking other metrics? Are you able to do thorough data tracking in your system? We are, as a nation, or as a team, we're actually lacking in these areas to sort out what are the ratios, what are the data, because still I am the only consultant during the morning periods. So we have a junior with me.

So we had the two doctors with, you can say, four or five nursing staffs for six or seven patients. So it was actually very difficult for me to make this data and to have any study or to keep it records. And also as a nation, when we grew up as a doctor, I look, I have done an MD and I'm doing the work. The research work as a country doesn't grow.

So we are not thought to make any case study, case series, or do research works in a routine basis. So as a nation, it's not become an habitant for us. We are doing lots of things, but to keep it in records or to keep it in data, I think these kinds of things we need to develop. Do you have electronic health records?

All your documentation is electronic for your nurses as well. Yeah. Okay. And how you said that you were working on family engagement. That was your next milestone. What kind of barriers have you faced with family engagement? What's it like in Bangladesh, culturally, economically, that play into family's ability to be engaged?

really involved in the ICU? Look, the general consensus among the peoples of Bangladesh or among the peoples of low-income countries in there, we are putting the patient unnecessary in an ICU. This is the first thing they think that we are putting the patient in ICU. Maybe some financial issues for us.

or the patient and unnecessarily. These are the first things. What the general people. Second thing is that as a nation, Bangladesh is a country where so many environmental diseases are there. And we are not very much accustomed to hand washing or proper hygiene. So generally, why not many ICUs in Bangladesh? You can say the 99% ICUs of Bangladesh just allow visitors for the one time, maybe in the morning or in the evening.

So it's more of an IPC controlling measures. And another thing that the general awareness about the health and the ICU is so like, so when a family member came to visit a patient in an ICU, so he's seeing that maybe we are tightening the patient's hands because the patient is restraining, maybe some putting them in an adjuvant tube or antitracheal tubes.

or the patients in deep sedation, the patient is, they think that the patient is no more and they tend to take the photos. So they want us to take, pass the patients and everything. So for these reasons, the family members only allowed for one time. So what, by this time, as we just allowing for the one time, what happens is that

the family and there is a miscommunication between the families and the doctors. So when a patient suddenly deteriorated, maybe in late night, the family members are not there, they're in the home,

So when we call them that this patient is deteriorated, so it's become a shock to them. Even we counsel them that the patient is bad, is critical. So when they come back, they tend to make a scene or they tend to make chaos within the hospitals. So I faced it for the last seven in my academic hospitals also where I worked before. So I have been working in my ICU for the last three and a half years. Still, there is not a single incidence regarding the patient deterioration

in my hospital. There is no chaos. There is no scenarios. There is nothing because I am very clear about the patient's family and very open with the patient families. Because what I feel that if you share everything with them, what is happening, what is the prognosis, what we are doing, what can be done, what are the other options, what are the options you can avail in the other hospital, which I don't have.

if we have a clear communication, then it sorted out most of the matters. Also what I found that we initially in my academic hospital also we tend to use high dose of fentanyl, high dose of profol, even neuromuscular brokers. So when the patient become an agitated, like the patient has been gone through for the first two or three days and he's or she's improving and when he wants to see the family members,

look the patient wants to see the family members in the morning 10 am my visiting time is 5 pm so if if i am not allowing the family members at 8 periods or 10 hours periods the patient becomes hesitated so then i put to i need to put the additional dose of midas the additional dose of fentanyl additional minerals are probable so when

Instantly, I make his or her family people in front of him. 50% or 60% of them is settled down. The patient has been settled down. And when the patient... I feel that it is more of a problem when the patient came out from the ventilator. When the patient came out of the ventilator, all the sedations, instantly they want to see their family members.

So maybe I extubated a patient at 12 am, my visiting time is next morning 12 am. So it is after 12 hours they tend to wait to see their family members. So instantly if I make visit his family member within that period, it is gradually decreasing down the sedation requirements, it decreases his anxiety and everything. So it's the weak things. Even within my hospitals we have been like

We have some IPD also. Everyone is strict about the visiting area.

So that is two things. One is that they came from the outside, that they have been infection controlled. Another one thing that the people tends to take the photos, tends to touch the patients, tends to hug the patients. So that's why. But in my family, I allow everyone at least two times is regular. And one, they find the family.

Emily also wants to see, or when the patient wants to see, I make a video call. I have two separate tables, one in the patient's side, one in the outside. So when we can't allow the patients to see them physically, we just make a video call to them. So it helps. It helps in so many ways. Yeah, that's so interesting. Culture plays a big part. Just thinking back to my experiences, different cultures have different responses to these things.

very intense emotional situations. I think Americans are a little bit more reserved. We don't show our feelings so openly, but then other people, they wear it on their sleeves, right? Their loved one is in a critical condition. They're panicked. There's also the question of medical literacy. When you don't understand what's going on, all of that is scarier. If the physicians aren't as open and educational as you are, then there's more mistrust.

There's just a lot. There is other issues also. Look, if I allow a patient who is in bed two, one family member came to see the patient in bed two and one patient crashed in the bed four. So we are doing the CPR. We are doing everything. As you know, there is some sounds going through when the patient, when a patient crashed.

So the problem that we are facing that number two best patients, family member going outside and telling that your patient has been crashed or your patient has been died. Did this happen? That happened. So that's why actually if though I am more open for to family members engagement, but it's still the problem rather than the mobilization because early mobilization is so much easier because it's a closed door thing. I don't need to engage the family members there.

But in the bundles of F family engagement, there is still so much of constant, so much so struggles to make it a regular, because these are the things it's quite happening. Two number bed patients going outside and telling the phone number bed patient that this happened, this happened, this happened. And it makes a chaos at that time. I hadn't thought about that because I saw on your videos and we're going to post those online.

that you don't have private rooms. You have an open area with basically shower curtains dividing these beds for privacy, but still everything is audible. And I've worked in an ICU before that had shared rooms. So two patients in one room and I've coded a patient in one bed and I've had another patient be very awake and watching the whole thing and, or at least listening to it. So I, but in the family wasn't even present during that time. So I can only imagine that

Trying to control the chaos of a code while having family members and people poking their heads out. And so that there are a lot of dynamics to consider when it comes to family engagement and the role in the ICU and all these different cultural, economic, the layout of an ICU, all that plays into how we can utilize families. Then you're making a really good point that the more families are there, the less sedation we use.

We treat anxiety with family engagement rather than masking it with sedation. And obviously that's better for everybody. It helps. I can say more confidently that I attach more family members than any other hospitals in my city. Still, there is clear communications. It helps in so many times.

And in 80 to 90% times it helps, but in 10% of time it creates a problem. But things are changing. I think it will be more helpful in future. That is fascinating. And I guess we didn't even really dive deep into your sedation piece. How have your sedation practices changed? Sedation practices changed drastically. Apart from the patients on ventilators, even the patients in ventilators, our sedation protocol is to start with the FENTA.

and then needs a dose of Dexmed or if need adding the propofol. We don't actually use the Medazil. So initially it was more often Pentamol, then we are now more often Dexmed because Dexmed has unconscious sedations and is easy to wake up the patients.

So initially maybe a patient needs 70 micrograms, 100 micrograms of Fentor in an hour. So first days, first one or two days, it takes more of sedation. But after two days onwards, the patients find out that the hemoglobin is improving when we are in the patients. Majority of time we don't use another, we don't continue the, at that time more often we

tend to immobilize the patients or engage the family. So yeah, it reduces the sedations. Therefore, you're able to mobilize them while they're intubated. Yeah. What advice would you give to other ICUs that are wanting to make these same changes, especially in your general part of the world? It's more often you need to be patient. First thing, you need to be more patient about these goals, like early mobilizations or the family engagements.

And I think the physician, at least for the first early phase of this implementation, the physician needs to be actively involved in this because you just can order a nurse to do this and he will do this because it's a big thing.

And another thing is that nursing ratios, low resources, it will be here in everywhere, in Bangladesh, in USA, in Europe, everything here. I think it's more of a passion that everyone needs because look, early mobilization is not an course or it's not a training that you can train everyone. So it's more of an, from your inner feeling that, no, I need to do this. I have to do this. Then it will be, I think it can be done.

and the entire team sees it like an antibiotic and a life-saving intervention, everyone joins together to make it happen. And especially once it becomes a skill set, it becomes much easier. Yeah, it's more often involving and engaging your staff and make them ready and make them really believe that and give them that trust that if anything happens, I'm here.

So don't worry, I can manage it or I will take the responsibility to make that trust within the team. And it will take time initially, but it will become in practice. As I told earlier, it was initially for one day, one time in the morning. Now it becomes three times like an antibiotics. Wow. Well, congratulations, Dr. Jahayi Dool Alam. I am so excited for you and your team. I appreciate that.

the revolution happening in your ICU. And I'm excited to have put you on the map of awake and walking ICUs. Thank you. To schedule a consultation for your ICU, as well as find supportive resources, such as the free ebook, case studies, episode citations and transcripts, please check out the website, www.daytonicuconsulting.com.