Episode 196: Delirium and Workplace Violence
01:03:32 Share

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.

A big focus of AACN this year is healthy workplace environment. A huge topic in the media has been workplace violence in the hospitals. I'm so glad clinicians are speaking out and sharing their stories. This is an additional reason why the ABCDEF bundle matters. It keeps not only our patients safer from death and long-term disability and suffering,

But by protecting patients from delirium, we are also drastically decreasing the risks of violence in the ICU and hospital. Patients with delirium are 11 times more likely to be aggressive and violent. One study showed that by just implementing the CAM screening tool, the number of violent events decreased. I am so excited to bring a true expert on the matter, an ICU nurse and survivor of workplace violence. Kelsey, thank you so much for coming on the podcast. Can you introduce yourself to us?

Yeah, thank you so much for having me. My name is Kelsey Springer. I am registered nurse. I actually just finished my master's degree a few weeks ago. And I am, oh gosh, I've been a nurse for...

Well, over nine years now, I've been in health care since I was 16. So it's been a big part of my life for a very long time. I have spent the majority of my registered nursing career in some form of critical care, whether it's been bedside in the ICU, I worked as the flight nurse for a while, I worked in cardiac cath lab, and then now I am a clinical nurse educator for an intensive care unit. I also am a clinical instructor at a university for nursing students.

So great. And you were referred to me because you are an advocate and an expert on workplace violence. And this is something I've been wanting to talk about for a long time. Because one, it's a hot topic. Two, I'm like, we both have experienced it. And three, because this podcast talks so much about delirium, that is absolutely an aspect of it that I don't think everyone can connect the dots on.

So I'd love to hear about why you got into being this advocate for workplace violence and what you're up to right now. Yeah. Unfortunately, my path to advocacy is because of a personal experience that I had. I was assaulted by a patient while working in an ICU and it has completely changed my life. It was a really significant event that led to some pretty big, you know, life altering things. And that

You know, one of the biggest reasons that I want to advocate is because I really had no idea that this could happen. And I had...

this blissfully unaware feeling every day I walked into work I had so many near miss events that easily could have had the same outcome as the one that ultimately did and I think that's really why I want to get out and share my story because unless you've experienced it firsthand I just don't think there's a lot talked about it or there hasn't been and I kind of equate it to

you know, when you have a near miss event with like a medication error or something that could harm a patient, you get that feeling, you get that feeling of like, oh my gosh, I never want to make a mistake again. I never want to be in that position again, because you don't want to harm your patient. But at least for me and other people I've talked to, it's,

not always the same when it comes to your own safety. We kind of brush it off. Nothing bad happens, you know, if you don't actually get injured and it's easy to forget about. And I kind of want to remind people that those near miss events, those almost things are still very significant. And we really need to do everything we can to prevent these events from happening. And that

really comes from a very holistic approach, which very much includes addressing delirium in our work environment. That near miss is, I'd never thought about that being applied to violence. And I'm already having so many flashbacks, so many incidences. That's exactly the way it should be put it. Those were near misses. And I would look back and be like, that could have been bad, but it didn't. So whatever.

And looking back, I'm like, that shouldn't have even gotten so close. And I've certainly, I've been headbutted at least twice, kicked, hair pulled, like I've had all the things. And when I think about those situations, almost all of those were in a setting of delirium. Yeah. And one that was a near miss that I'm thinking of that could have gone really, really bad was, it was alcohol withdrawal. And I don't think he was delirious yet, but he was withdrawing, he was escalating. And so was delirium part of your assault?

Yeah, in a way it was. And I don't really and I don't even need to go into detail as to what, you know, the patient was experiencing because they were unaware of their environment. They had no idea why they were in the hospital. They didn't know they were in the hospital.

And they were afraid. They were acting in what they felt was self-defense. And I think that is so common in the ICU, especially no matter if it's a head trauma, if you've got someone that's electrolytes are out of whack, you've got someone with a UTI, you know, alcohol withdrawal, substance abuse withdrawal, any one of those things always

you know, is high risk of delirium and already has, you know, this nature of being just confused. And I think that is something that we don't recognize as being a risk factor for workplace violence. And we should, I think one thing that I've

kind of coined, I guess, is, you know, we've got these universal precautions for bloodborne pathogens and all these other things that could make us sick that could, you know, harm us in some way. Why don't we have universal precautions when it comes to

potentially having a violent patient you know not just that we've got someone who's angry and wants to hurt us you know that's a that's a portion of them but that's you know a small portion depending on where you're working and then there's this huge other portion that there's all these different risk factors that we just don't commonly associate with the potential for violence and we should and oftentimes we're not even screening for it I find in the ICU

that a lot of our CAM assessments are not happening, not happening accurately. Patients are either too sedated to screen for it or they come out of sedation just long enough to get resedated before we can even screen for delirium. Our

Post-ICUs or step-down units or acute care units are not screening for delirium. They don't have delirium screening tools. And one study that I saw looked at post-acute screening in neuro, those post-stroke patients primarily. When they looked at more to the inattention and disorganized thinking, they were able to screen for a lot more delirium.

and probably catch delirium a lot sooner. And they found, and the only outcome they were measuring was, does increased screening impact violence? And they found that it did. What are your thoughts on that? Why, I mean, sometimes we think of screening as diagnostics, but how would screening improve our safety? I mean, I think it really goes down to

you know, us at the bedside truly understanding what the screening means. You know, we can put all these tools together. We can have all these things in our charting system that give us a green flag, a red flag, whatever it is. But if you truly understand

are doing the screening meaningfully and not just going through the motions, then it really triggers you to be like, okay, you know, if these things are positive, that means my patient doesn't know what's going on, that, you know, they're not necessarily going to be redirectable in the way that someone else might be. And that we need to understand that their reality is very different from what ours is in that room in that moment. And I think it's,

You know, if we have this kind of light bulb that goes off in our head that when that screening is positive and what that you know, what is positive in that screening, then we can really understand what our patients feeling and what their reality is and be able to care for them appropriately in that manner. And not only, you know, trying to address.

the ways that we can mitigate, hopefully reverse that delirium, but also know how to take care of them and take care of them in a way that is meeting them where they're at. You know, it's similar to working with someone who's got Alzheimer's, dementia, something like that. You have to meet them in their reality. You can't just keep yelling at them like, hey, you're in a hospital, you're safe. You know, you have to

be able to understand that they may never be able to understand that in the mindset that they're in. So how do you really show them while also protecting yourself?

and trying to resolve the delirium at the same time. And it's, you know, a complex thing. And I think, you know, historically in, especially in my early career, when I was learning about CAM scores and all of that, I went through all the things, I did the whole thing, and then I plugged it in and it went into my charting thing. I reported it off at rounds and then

I don't know that I really thought about the holistic picture of like, yes, my patient is CAM positive. And why and what are they experiencing? You know, it just was another box to check. And I didn't really take it seriously. And the team doesn't take it seriously either. So you report it around and they're CAM positive and everyone's judged and said, yeah, so is most of the rest of the unit. And you just move on instead of stopping and saying, this is a medical emergency. This is acute brain failure.

This is doubling the risk of dying. What's causing it? How are we going to treat it? And how are they behaving? And are you as the nurse safe with this patient that is very confused and going to be on the defense most likely? I find that we don't have the tools in most teams to prevent and address delirium in that way. And therefore we inadvertently escalate delirium and the level of agitation that happens. One study looked at

comparing medical ICU to surgical ICU, looking at do these different risk factors between these two patient populations increase the severity of delirium? And they found that the medical ICU had a lot more predisposing risk factors for delirium, right? A lot of comorbidities, a lot of certain current diagnoses that increase the risk of delirium. So older patients, you just would have thought that

delirium would have been more rampant and more severe in the medical ICU. The surgical ICU had much simpler patients, younger, healthier, and yet surgical ICU had a higher severity of delirium than the medical ICU. And they determined that it was because the surgical ICU received more sedatives. So we increase the severity of delirium as well as prolong the duration of delirium by giving more sedatives. And yet when someone is confused,

when they're starting to get restless. We call that agitated, but really it's restlessness, they're fidgety. How are you taught to respond to that kind of behavior? Yeah, well, we want to use the tools that we have at hand, which most often are more medications. And I think that's something that, you know, yes, there is always an appropriate time for that, you know. But one thing that I have personally experienced working at a few different health systems and things is,

How do our interdisciplinary teams and that also do we include security as part of our interdisciplinary team? And how are they all trained to understand and respond to delirium? And I think that's a really big part of if our physical therapists, occupational therapists,

You know, even our respiratory therapists, if our whole team doesn't understand how to work with these patients and that they are part of our toolkit. And if they don't understand and they're essentially not part of the toolkit, then our toolkit really is medication unless we have multiples of us, which there often aren't. So I think that's a really big factor in kind of that holistic approach to delirium treatment.

Absolutely. I have this image that people love. It's of a SWAT team. And I have them labeled as PTOT SLP, the delirium SWAT team. And of course, whoever is engaged in preventing treating delirium is part of that SWAT team. But I looked at that as kind of the perspective of a nurse saying, who can help me with this? Who's my backup? Who's my toolkit? Who's going to help me intervene? But that's not a shared perspective. So a lot of times if they are

confused, if they're restless, if they're kind of sleepy, we as nurses can block out the door saying, that's an excuse not to mobilize them. They're too confused. Not today. They're too tired. They're too agitated. And then our SWAT team can't come in and work with them. And in the case of continuous sedation, or even Karen bolus sedation, like out of van, even I think how it all like, we are fine off the top of our grenade and handing down shift to shift to shift.

That's how I see starting sedative drips or an Ataman CWO protocol. The burden is going to fall on someone and it's always a nurse who have to DC that, have to do the awakening trial to stop the CWO protocol. And now all the agitation and terror and confusion and fight or flight that we've caused underneath the sedation is now unmasked.

And it's going to rage against usually a nurse or an RT, whoever gets to be unfortunate person that really gets to have them totally unsedated and floridly delirious. And it is so unsafe. So it's not just what we do in the moment. It's what we do upon arrival to the ICU, the hospital to say, how are we going to prevent that detecting those early signs to say, hold on, they're starting to have some inattention. Something's going wrong. What are we going to do? And how do we make sure that

our experts have access to those patients because I think nurses feel like they get to deal with the agitation alone right but that's not safe it's not feasible it's not fair and it's not necessary so what has helped you broaden this perspective you said you know the beginning of your career it was just checking the boxes you had this personal experience what's helped you connect the dots the scene the learning management is part of protecting yourself as a nurse

You know, I think that's something that I'm, you know, still on kind of this evolving track of, but I think really being able to connect it to, it's not just my patient's safety, it's my safety and it's the whole unit's safety. In order to adequately care for our patients, we need to be in a safe environment to do so. And that is,

Being a driving factor for wanting to understand and learn more has then really opened up a lot of doors for me to really see and understand, hey, what is the importance of doing these things and these tools? And then looking deeper into the research of actual outcomes when you have patients who have delirium and diabetes.

the worsening outcomes that they have, the ICU liberation is delayed. There's so many different factors that go into just ultimate good patient care. Unfortunately, it's taken me experiencing something so significant that I've always been a nerd when it's come to really understanding different disease processes and being able to understand, oh, I can give, you know, this electrolyte and it mitigates this effect and all these other things. But

You know, unfortunately, delirium doesn't have that same excitement to it for a lot of people. It's not hot and sexy, right? No, you know, it's not. With lines and tubes and drains and medications, you can't have like instant control over it. Yeah, and it's not immediately life-saving necessarily, like in that moment, like getting rid of a lethal arrhythmia or something like that, but it still is very life-saving and it's,

quality of life saving and not only for our patients, for us and our units as well. You know, I think it's something that unfortunately takes time.

some dedication to dive into and to learn about, but it's so worth it. And that's something that I've really been learning is just really understanding the whole patient when it comes to ICU care. And I didn't always think that way. So I'm really glad that there are people like you who are out there and kind of leading the crusade because it's a very important aspect of ICU nursing and just holistic ICU care in general.

Working in an awake and walking ICU, obviously there was delirium, but not at the same frequency or severity compared to other ICUs that I ended up working in. I didn't appreciate that because it was my first ICU. I didn't know anything else. I felt like patients were confused and restless, but I didn't feel necessarily unsafe around most of them. I was also in my early 20s, so I was kind of felt like I was immortal and I seen people get seriously injured.

I don't know if some of it was naivete or really these patients were not that dangerous and it didn't last as long. Again, comparatively now looking back, I'm like, yeah, this was much safer environment. I didn't know anything else. But when patients would come from outside facilities and they had been sedated, it was so stressful. So you would take it off. Again, I didn't know all the why's.

But we take it off and now they're like trying to self-extubate and they're thrashing and they're levitating off the bed. And it would take four of us to hold them down while we try to figure out what sedative level to get correct so that we could then set them up, mobilize them. So it was part of the conveyor belt to take a patient that was a RAS of plus four, especially if they're delirious, to then get them to more of a RAS of plus one. Because RAS of plus one, I could handle. Plus four, that was dangerous. So we kind of knew what was dangerous and what was okay.

We had a much bigger threshold for movement, shifting your own body, fidgeting. That was fine. We'd use sedation to get them down and then we would start to move them, set them up. And that was a whole team's approach of, all right, we have to do this. And I think if we had received those patients from outside facilities, they were RASA plus four, and then we put them down to RASA negative two, it would have changed everything. They would have been stressful and scary every time we turned sedation off.

They would have had poor outcomes, which definitely would have changed my fulfillment in that ICU. So working in a different environment where people are so afraid of patients moving, I felt less secure because if no one was going to help me with this patient, no one even wanted me to take sedation off. And when I did, they came out a hot mess and I was alone with it. It was a lot of insecurity for me as a nurse to figure out how to navigate that. And I still didn't understand.

This is a life-threatening brain failure. This is a big deal. I didn't understand all those things. I just knew that it felt unsafe. But looking back prior to that, I did all sorts of things that would have made a lot more people scared, but it was in the right environment in which we knew we were going to put forth a group effort up front so that everyone's job is going to be easier for days to come with that patient. But also having one patient out of, you know,

20 patients be that delirious is a lot easier than having 80% of those patients be delirious. Yeah, absolutely. And I think this is where having that highly trained interdisciplinary team, you know, not only trained in recognizing what delirium is and how it's affecting our patient, you know, so that we can all come with our

specialty, the things that we're good at and care for them in that way. But then also have training to be able to deescalate that situation and how to safely intervene physically if you need to so that you feel safe and the whole team around you, you know that they're all safe and have the right tools to do that. And that's where I personally would love to see

security become part of and seen more as that interdisciplinary team. I've seen in some hospitals where security members are given a basic amount of medical training. So essentially they understand medical terms in a basic way so that nursing, speech, physical therapy, everyone can communicate with them.

And they understand we're all speaking the same language, essentially, to keep our patients safe. And in an ICU setting, I think that's so important because we've got these really awesome team members in security who are there to help us. But if they don't feel comfortable around the patient because they don't want to harm the patient because they don't understand what's going on.

And it's important for us to be able to communicate with them to help so we can all collaboratively work together. So then if we do have a patient that is delirious and we need to do these things to help bring that delirium down, maybe we're a little afraid to do some of those things. That's where having that whole interdisciplinary team helps.

be able to be present and effectively care for that patient. Because if we're continuing that cycle of just slamming meds and putting the patient back into a very sedated state, that cycle is just going to continue. We're not going to be able to break it. But if we have all of our team members not only understanding delirium, but also understanding de-escalation and safe physical ways to help

If a patient does become violent, we're all going to be able to operate way more effectively. And the chances of us actually needing to intervene physically are probably a lot less if we're all on the same page and all can communicate well and all know how to take care of that patient from that delirium. Absolutely. I think that kind of training is not standardized. That's something I really focus on when I train ICU teams. So I think it kind of surprises them because they're expecting us to come and just talk about mobility.

But a large part of my focus is agitation prevention and management. What do you do when they're a RAS of plus one or plus two versus what do you do when they're a plus three or plus four? By taking those steps at a plus one or plus two, you're in large part preventing escalation to a plus three or plus four. If someone wants to write because they're afraid of their kids being kidnapped and you tie them tighter, how does that not escalate? So we talk about nonverbal communication.

what kind of tools patients can use in different physical conditions, how to allow them to ask whatever they need to ask beyond just yes or no questions. And I think during those conversations and during that kind of training, so fun to watch light bulbs go off where these clinicians that are very skilled in these big, hot, sexy interventions,

are suddenly realizing and connecting the dots that because that point they've already had didactics, they understand delirium is a risk. They understand the dangers of it. They are understanding patient reality. So when they're practicing the logistics of how to manage that, you can see they're like, wow, a pen and paper can save lives. Wow. Maybe, maybe we don't need to just jump on them with sedatives at a RASA plus two. Maybe if they are fidgety and restless, they're,

They're not necessarily dangerous yet. Let's sit them up. Let's get them their hands free in a safe environment and monitor so that they can calm down. Maybe keeping them supine and tying them tighter is not going to help keep them safe or me safe. I think what we oftentimes do in the ICU is we keep on that cycle, like you mentioned, agitated sedation, agitated sedation until they don't have any fight left until they're so weak, they can't lift a finger.

I have seen that so many times. That's no one's intention. But as a nurse in that moment, you're there for that one shift. And you feel like your one job is to keep that tube in. And you're alone. You feel very unsafe and very vulnerable.

But in the end, if we do that, we're setting up the next nurse for greater risk and the next nurse and the next RT and the next physical therapist that finally gets to go in and work with them, whether it's a risk of violence against them, or I think even just an injury of having to then later move a flaccid body. So.

It's really not safe. And also, if we're just trying to keep the tube in, delirium increases the risk of pulling that tube out by over 11 times. So what we think is safe is actually very dangerous. Do you find in this realm, in this area, as you're advocating for safe workplace environments, do you find other people understand delirium as a key player in this? Or are you having to teach them about it?

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.

I'm definitely new to this advocacy work, but through the people that I have talked to, and there was one study that I found that was a systematic review. And it essentially said that, you know, up to 80% of violence in the intensive care unit is due to delirium or has delirium as an aspect of that patient, what they've got going on. And I think that is something that like eyes wide open. And when I tell people that,

And I think, again, when they think about it and they look back to it and they think about all their near misses, they're like, oh, yeah, like my patient wasn't really, you know, it was not an intentional thing. It wasn't. And there's there's plenty of that as well. But I would say almost 100 percent of nurses working in the ICU that I personally talked to have had.

a near miss story related to a delirious patient. And I mean, it goes back to, you know, Maslow's hierarchy of needs and that patient doesn't have the basic needs met for them to feel safe. They're going to do whatever they can to try to protect themselves. And, you

That makes a lot of sense, but we just don't connect those dots. And I think there's, as you have said, there's so many reasons why delirium is important in our patients' long-term outcomes and preventing that delirium, mitigating it as soon as we can.

But I think the potential for violence is just not the most commonly thought about thing. And I think it's just another great reason why this really needs to be at the forefront of that culture change in ICUs. When I talk about awakened walking ICUs to people that have never heard the concept before, and I explain that we don't give sedation unless there's an indication for sedation. So most patients, even if they're intubated, do not have any sedation running.

not even PRNs, unless there's an indication for it. And I see their eyes get big. And I know that what they're automatically envisioning is a unit full of patients thrashing, hitting, pulling out their tubes, going insane, because that is what they experience when they do awakening trials. So for most clinicians, they've only experienced starting sedation and then taking it off days later, where there's oftentimes emergency agitation, usually rooted in delirium.

What they don't get to experience is what patients are like when they first come out of those induction meds from intubation. And they're coughing, gagging initially, but they still have their coping mechanisms. They can still understand this is the tube that's keeping you alive and they can acclimate and they calm down and they write and they maybe don't have to be restrained and they stay calm. And we can use all these other non-pharmacological interventions to the greatest effect because we're not giving them delirium.

Once clinicians experience that, they don't want to go back. They're like, this is one better for my patients, but also it's safer. I can trust them. I can talk them through things, but it's so much higher risk when we're now trying to clean up delirium on the backend. So that's what I'm so passionate for the clinician safety and ease and feasibility to have delirium prevented, not just treated, but prevented. When I am at conferences, I'm,

Especially with nurses, I have them raise their hand if they've been assaulted by a patient. And almost everyone raises their hand, which is so painful for me to see. Then I invite them to put their hands down if those assaults included patients that knew what was going on, that were not confused, that did not have delirium. And hardly anyone puts their hands down. And it's pretty profound to have them look around at each other and like, yeah, but that's the first time they're really connecting the dots there.

And yet we're really trying to work towards workplace violence. But I don't see a lot of delirium being mentioned in that. Yeah. And I think that is a big reason why I have a huge passion when people come to me and ask, what are the big things that I'm advocating for when it comes to workplace violence prevention? And they're really surprised when they hear me say yes, having...

it be across the board a felony to assault a health care provider. Yes, that's a thing. That's a reactionary thing. As well as, you know, having metal detectors and things like that. Yes, those are very important things. But that's not

at all scratching the surface of all of these things that we can do. And number one is depending on where you're working, understanding the patient population and the risk factors that are increasing that patient population for healthcare violence. One of the really interesting, there's an interesting article that I read and it essentially talked about having security officers

see the hospital as like little neighborhoods. And they kind of would then get to understand that neighborhood similar to how police officers understand different neighborhoods, what's going on in those neighborhoods and that, you know, how they react and how they approach that neighborhood is different because they know the history and background of it. So the way a security officer might enter a room or react if you have a violent code thing that gets called overhead is

they're going to react different in a psychiatric unit versus a labor and delivery unit versus an ICU. And that's because understanding what that underlying patient population is and being able to then go in and treat that patient population for whatever, you know, is going on. And it's not just the security officers that need that. We need that as a whole as nursing. We need to understand that.

Violence is a huge risk no matter where we work. And that's really, really unfortunate. But there's so much we can do to prevent it, to keep ourselves safe. And so much of that is understanding where we work and the patients that we take care of.

And then applying this, again, this holistic approach of knowing the diagnoses that are associated with high risks of violence, recognizing those things. Oh, is my patient starting to show signs of violence? Why is, are they delirious? Or are they having a mental health crisis because of whatever diagnosis they have going on? And we need to understand and get the right tools in place.

Or are they unfortunately someone that just wants to cause harm? And then that's something we need to recognize as well. We're going to approach that differently than we're going to approach a patient with delirium versus approaching a patient who is having a mental health crisis. And those are the things that I'm a huge proponent for. It's not just a one thing that we can do and blame all these patients and

go ahead and put them in jail after they're out of the hospital. That doesn't prevent anything and it helps no one. And a good percentage of the time that's not indicated at all. But what is indicated is just more holistic patient care and really understanding the root cause of what's causing all these violent episodes from happening. I love it. I know we keep on tying in safe staffing with this, which is absolutely, but I think

A lot of times we're imagining more people to hold more people down instead of more people to provide better care to prevent all these causes of the agitation of the violence. Ironically, my brother is 22. He is an MMA fighter. The sweetest, snuggliest, most tender uncle. He's 6'3".

And he is super tough, right? He's like semi-pro MMA fighter. He's also a hospital security guard in Arizona. And he told me crazy stories. And so I know that he would come in guns a-blazing, ready to defend and protect the clinicians. But he's also very tender. He has a high emotional IQ. If he got the kind of training to say, hey, maybe we call different kinds of codes for someone that's delirious. If he knew that,

And maybe, you know, that someone that just him having his security guard garb on renders respect, a little bit of intimidation. That alone, maybe they just need that physical presence in case he does escalate, but also for having him know, this is someone that's confused. This is someone that doesn't need someone just automatically jumping on top of them.

This is someone that maybe he as a third party, that's not someone, maybe they already think the clinicians are the perpetrators and they think he's a policeman there to save him. Maybe he can play into that scenario a little bit and know how to navigate that. I know my brother would be willing and able to do that, but has that role been defined for him? Keep on thinking about another situation, which my colleague and NP was on the unit and there was,

a little bit of a hotheaded nurse having an interaction with a patient. And I don't know if the patient had delirium or not, but it was escalating. So they called security and this NP, her name is Louise. She's like five foot one. She's tiny. She goes in, she like pushes everyone to the side. She's like, get out of the way, get everybody out. Everybody get out of the room. And, and they're like, at least you can't just be in the room with him. She's like, it's fine. Get out. And she sits down on the bed next to him and says, what do you need? What's up? What's your problem? And he calmed down.

having everyone out of the room. And I don't recommend that for every situation. But I do think we need to have algorithms, triage, training and sort of have critical thinking. But sometimes and a lot of times, jumping on someone is not the answer. I also am really passionate about having a clear understanding of RAS scores so that we can communicate that. So if someone calls me as an NP and they say, hey, my patient's agitated. If I imagine it's a plus one, I'm like,

then talk to them, deal with it. But if they call me and say they're Rasa plus four, I'm going to say, okay, and put, give them an X bolus and I'm coming in right now to the bedside and I'm going to grab the church nurse on my way in. So that is a different level of communication. But right now when we say agitated for anything that opens their eyes and shifts their body, then we don't necessarily have the right response to things. We either over-respond or we under-respond. So when you have clear communication and that needs to be

translated across the disciplines from RT to CNA, PT, everyone needs to speak in RAS. And maybe even somehow communicating that to the security. We call it code gray, maybe code gray A. I don't know. I think we have so many codes, it's hard to memorize them all. But or as they come in and say, hey, this patient has delirium. Now they're already thinking about it.

Yeah, and have almost like a quick little at the door, free brief of what you're walking into, because I think that is something where calling a code blue, we're a very algorithmic, we're going to do basically the same thing every time. And that works. And that's how we get ROSC, we get good outcomes. These, you know, code grays, these violent codes,

These situations are not the same no matter what patient it is, even if the patient age, diagnosis, weight, all the things are the exact same. It's going to be different every single time because now we're dealing with human emotion and human cognition, not just the cardiac system or the respiratory system. You know, we're also dealing with those things.

What we're dealing with so much and we need to make sure that we're not just having this one size fits all approach. And I think that also plays into are we simulating these things? Are we having simulations where we can practice this and practice what's our move versus maybe our gut move is going to shift a little bit with more education and more understanding and more practice.

And also when we're doing our interdisciplinary rounds, you know, are we including people

We're obviously a lot of times including our PT, OT speech, all of them, but are we including security potentially? Are we giving them a little pre-brief on, hey, I've got this patient who they're young and strong and they are delirious and we need to get them up and start doing some things with them. And we're afraid to do it because none of us want to get hurt, but we know we need to do it. And...

can you come help us? Can you be there with us? And how do we incorporate that whole thing so that

We're not just skipping it altogether. And there might be some instances where we have, you know, an identified patient who has caused significant harm to someone and we need to mitigate, you know, certain risks. And again, every situation is going to be different. But how can we use every single tool in our kit to successfully care for patients while keeping ourselves safe?

I haven't seen this quantified in the research, but it's my suspicion that our young, strong patients end up receiving more sedation. I'm sure they metabolize it quicker, but I'm sure they end up more sedated, like a lower RAS, or at least for longer. That's the research according to Kaylee. In my own brain, I just have high suspicions that I haven't seen research for. But I've seen it happen where our fear influences our practices. My brother, again, the same one, MMA fighter,

was fighting a kid that was a pro. He had an unknown undiagnosed cardiac condition. He had been maxing out on caffeine. So my brother had him in a headlock and he, he flatlined. They didn't realize that like, I think, you know, wrestlers, they pass out. And so it took him a while to realize that he really was having an arrest and to start CPR. So he gets frosk again after it was like 20 minutes down. It was, it was not good. So he had an anoxic brain injury.

And while in the hospital, I had him intubated, but really they had just had them intubated to do imaging. He should have been extubated, but because he's got tattoos, he's a pro MMA fighter. He's young. He's got lots of muscle mass. He was confused because he had a brain injury. They kept him on like three milligrams of Versed for, I don't know, it was like 10 days or something, but he had a brain injury. Did we need to be giving neurotoxic meds on top of that? But they were scared.

I don't blame them for being scared, but maybe he would have been on a verticalization bed standing while they bring down sedation. Maybe they'd got him moving right away. All of things would have helped deescalate

any kind of movement, agitation. But I think about having security there just so that the clinicians feel safer. Absolutely. And when you have them present on the unit, more often just for grounding and being a presence and you get to know them, same with doing simulations and things like that. I think you feel a lot safer just having that connection, you know, with that person, knowing that they're there if you need anything, but you can continue on caring for that patient and you know you've got that safety right there.

And I think that's huge. And I think that's, again, why when I have traditionally worked at smaller hospitals where, you know, we don't always have certain specialty physicians and stuff available 24-7. So we only do certain things when they're in-house, you know, because we need that safety net. So...

Why is this any different? Get that safety net there, but also have a relationship with them. They shouldn't be someone that we just know when they come while there is an escalated patient. We should know them really, really well so that when we're in that escalated situation, we already know how they operate. We communicate with them well.

We know what they can and can't do, and they know what we're going to do, you know? So we, again, can continue to give really good care instead of just going immediately to that, jumping on the patient, tying them down, and sedating them till they're totally unaware of what's going on. And again, sometimes you need those things, but do we need that every single time? Probably not.

And are we doing that every single time because we don't know anything different? Probably. So many good points. I'm thinking about

The hospital that I trained, it was probably six months later, they had an event. It was a patient withdrawing and it was medically not managed super well and it escalated. And so they were having system-wide debrief on it and to figure out root cause analysis. How do we do better? They had a security in there and the nurses were frustrated because they had called the code gray. Security had come, but they said at the doorway and said, is this the right room? While they're wrestling this patient,

And it's clearly a situation, but the security guards were taught to verify this is the right room, to ask what's going on, to get some sort of debrief. And the nurses were expecting them to just jump in and help. It was a hot mess. It was dangerous. They needed them right then, but they felt like they just hung in the back and were filling things out. How much easier that situation would have been and safer it would have been if one medical management had been a little bit up to date. So I, side note, not all the providers attended the training. Okay.

And so that's just an example of why everyone needs to be trained on this. This is not just a nurse and PTOT thing. This is physicians involved because it ends up crashing our nurses when our physicians don't know how to manage this correctly. But also, if there's been clear communication and maybe I should involve security in some of these trainings or have them do their own trainings focused on this together,

So that those situations are much safer because everyone knows and expects the same thing from each other and know what the rules are and how to collaborate. Yeah, and I think we see that across health care. When we're all operating in silos, it doesn't work. I think the whole practice of interdisciplinary rounds, you know, like that is so that we're not operating in silos. It's so that we can collaborate, have collaboration.

teams doing different things, PT and OT coming in and co-treating a patient, us using physical therapy when we also need to do some other cares so that we can do, you know, multiple things at one time, but also so we're all understanding what the ultimate goal is, what the patient goal is for that day, for that hour, and things that we're looking out for so that we're all on the same page. And I think that the more we have seen

the spotlight on workplace violence. And unfortunately, the events that have happened that have led to

spotlight being on it, the more we're seeing how there are some key components that are being in silos. And we need to, you know, it's not traditional that we have a security team as part of a healthcare team. But one facility that I have worked at in the past security officers all got basic EMT training. And whether they were hired on as that or they got it in their in their training, though, they all had that basic understanding of medical things. So

So they actually came in and did our compressions during code. Like they were part of our medical team in appropriate ways, but that also gave us that interdisciplinary. We got to understand who they were. They got to know us. They understood basic medical things so we could communicate well with them. You know, Hey, this patient, you know, in the ICU is getting very escalated. We need your help to come back.

take care of them. You know, we can tell them, hey, they've got this central line in their neck. They can't pull that out. They've got IVs in their arms. If those get ripped out, no big deal. Like being able to communicate so that they can appropriately, you know, if they need to touch a patient, they know how to safely do so. And they're not afraid of harming the patient because that's a huge mental block and emotional block for them as well to come in. And, you know, this isn't

security at the mall where you have one goal and everyone's kind of treated the same. This is healthcare security management. So we need to be able to include them in the healthcare team as appropriate, but they- They're not all shoplifters. You're just going to tackle down. Right. Absolutely. And I think we will see an evolution of that over time, but I think it, you know, we need to start thinking about now. So we're not wanting to treat everyone as villains right there in the moment, right?

And yet, I think there should be criminal prosecution for patients that do harm and hurt any of our clinicians, right? Healthcare providers should not be secondary. They should not be like, well, it's part of the job. You undertook this risk. So sorry, you have a brain injury. Sorry, you had your arm snapped. Sorry, you had your face beaten in. Like that's absolutely inappropriate. The situation in Florida with a nurse that was left alone with a high risk psychiatric patient

is a certain situation that should never have happened. Yet I'm in survivor groups and I've seen a few posts, like two or three, with survivors that say, I don't remember what happened, but I'm being criminally charged for hurting a nurse

I never would have done that on purpose. I don't remember what happened, but I guess they said that I did it. And it just makes my heart sink because they're in a survivor group. They're talking about their delirium. And now they're saying I did these things when I was not in my right mind. Should they be held liable for that? I think that is, that's a really hard, I don't think it's totally black and white, but I think for me personally,

I felt very comfortable ultimately making the decision not to formally press charges on the patient that assaulted me because it was very, very clear that it was not an intentional in their right mind. And it was something that I kind of put different people in this patient's shoes. I'm like, if it was someone that I knew and loved,

and they were in that, had the same diagnoses, had the same things going on, I would have the hardest time holding them criminally accountable. Now, I think they...

absolutely need to be aware of what they did and maybe that opens up some insight into potentially some other things going on in their life whatever it is but I think it's a very personal decision for the person who's been assaulted you know kind of determining you know whether or not

They want to press charges. And then a lot of it ultimately ends up in the court systems too, because patients a lot of the time cannot be held liable for those things if they are not. And it's very clinically documented that they are not in their right mind and do not know what's going on. I think there's a lot of differentiation that needs to happen when you have patients that are known high risk psychiatric diagnoses and things like that. And then that's where

hospital systems come into play as well versus having a patient in the ICU who, you know, heaven forbid your brother end up with

some kind of electrolyte abnormality and he ends up in the ICU and he's obviously very strong and very capable of physically taking care of himself in a defensive way and maybe he's got some electrolytes that are off he's really dehydrated and he's totally confused and defends himself like any one of us could end up in that kind of a situation so that's where it again comes down to

hospital systems needing to be responsible for providing the training and the systems in place to be preventing these kinds of acts. And that also means appropriately placing patients where they need to be. And if they can't be in those areas, number one, why? And number two, do you have a safe alternative?

that and then safely care for the patient and if not then that's something that someone needs to be held responsible for yeah let's say my brother did end up with hyponatremia or something right and now he's confused he's getting combative now we're giving him prostate strip to keep him down to negative two or ativan pushes around the clock and that goes on for days and now he ends up with a brain injury from delirium and now he needs two weeks of rehabilitation

And maybe he hurt someone during that time. That goes to court. Then that'd be an interesting conversation to say, listen, he came in with this condition that altered his mental status, but then look at what he got. He was getting Ativan pushes every two, four hours. That made him so confused. But also now he can't go back to work because his brain doesn't function. Now he's got horrific PTSD. Does that get flipped around onto the hospital to say, holding you liable for this change in quality of life

in this loss of financial security because he cannot no longer work. I think that stuff needs to be brought up to figure out who's liable for what. But ultimately, how do we keep like a roster of these patients to say, keep an eye on homeboy there. He's young, he's strong, he's confused. It could escalate. How are we as a team going to prevent this from becoming dangerous for us? But how do we also keep him safe from a brain injury? How do we communicate this to security so they know him if they have to come up?

And I worked with Polly Bailey, who is the founder of Awaken Walking ICU. And before COVID hit, she's so visionary. She was coming up with these safety rounds where we as NPs would go around

during the day shift, during the night shift, and do rounds and not like the thorough multidisciplinary rounds, but a quick lightning rounds. And there was a criteria. So you're looking at risk of hypoxia, risk of line two removals, falls, altered consciousness, delayed intubation, pressure injuries, looking at the potential risks. So trying to be really proactive and preventing them and kind of teaching the nurses of what do you think they're at risk of?

And then we'd have these little magnets, which I know we clutter our doorways with so much crap, but it was really informative to have

a yellow or red level of risk. So if it's actively happening, like if they're on 90% high flow and 60 liters and they're confused and keep pulling it off, we're going to put high risk of hypoxia or delayed intubation right there. So if you walk by the room and they have their high flow in their hand and you see that red on the doorway, you know, they're confused. They shouldn't have that off. They're going to die. We won't have to intubate them. So it's a quick communication to everybody. But that way, if you

have someone that's unrestrained and they're looking suspicious, but you don't see that they're confused on the doorway and you get closer and they're yonking in their mouth. Okay, you don't have to tackle that patient, right?

Right.

I don't know all their diagnosis, but I know I can help them to the toilet. That needs to be happening throughout our entire hospital. Nurse manager or charge nurse needs to be able to say, I have these five patients with delirium. That way, when PT and OT comes and says, who's top priority today? They say, boom, these patients need to be worked with immediately. Otherwise, we're going to have a really tough shift. So having the entire hospital, but that requires us to actually screen appropriately for delirium, which like you said, even deeper down requires us to actually know about it.

address the roots of the culture, which is education, beliefs, prioritization. Then we're screening for it. Now we can communicate with each other. Now we can actually appropriately intervene and create a much safer environment. We know that delirium is a huge psychological burden to nurses. I think part it's because we feel bad for them. They're miserable, but also it makes us miserable. It's a lot of stress and it's unsafe. What other advice would you give

to hospitals, to ICUs especially, about creating a safe environment? I think it's one of those things that...

There is a lot of data supporting a lot of this. Unfortunately, workplace violence and especially in the ICU is on the lower end of the amount of data that's out there. But there's so much data to support all of these other kind of contributing factors, especially to delirium. And I think it's some of these things that when you look at the bottom line and the cost of these things, I mean, injuries.

And severe injuries are hundreds of thousands of dollars. And it's affecting workman's comp insurance and all of these different things. It's affecting your burnout rate. It's affecting your unit morale, all of these different areas that ultimately just affect the unit as a whole.

And there's so many things that we can do to enact these preventative measures. And yes, they're really big culture shifts and they might not be able to be done overnight and it might take a while, but even just finding a couple of key things to focus on to improve that unit culture in terms of how we're recognizing violence, how we're screening for different things that can contribute to it and how

especially delirium screening, that's not just going to mitigate violence. That's mitigating so many things. So it's kind of a big bang for your buck kind of thing. And I think it's ultimately like

You invest now to save in the future kind of a thing. And it's not only financially, it's patient outcomes. It's cost of turnover, cost of, you know, injuries to your staff, cost of poor outcomes to your patients. There's so many things and it can feel really overwhelming when you look at taking on all of this stuff. So being able to do, you've got your cookbook of all the things you should do and pick out

a recipe or two, pick out a couple of things to focus on. And when you've mastered that, pick out another one and kind of slowly get those shifts happening. And that's really what contributes to that culture change, which ultimately pays out in multiple ways. Yeah, obviously the problem of workplace violence is very multifactorial, very complicated. So many things to consider. I think we're both in agreement that if we focus on delirium first,

That's a low hanging fruit. We're going to be able to make a lot of changes and prevent a lot of violence just by focusing on delirium. And it needs to be hospital wide. For example, when the ED gives an agitated patient Ativan and sends them to the floor, they're going to come out with more emergency agitation. They're going to be even harder to manage that delirium is going to last longer. And then the floor is usually trained to respond with more Ativan.

And if they end up at the ICU, they're already coming very confused. And now maybe they're needing to be intubated. Now we have higher risk lines and devices in place, but we're having to deal with that agitation. Or we start it in the ICU and we send it to the floor. So maybe they're sedated under our care. We get them extubated. We send them to the floor. And once that sedation is really worn off, now they're really confused. And now they're a fight for the floor. So it all just is a burden to everyone. So the entire hospital needs to be on the same page of,

screen for identifying, preventing and treating delirium so that the burden decreases on everyone as we get these patients out sooner by preventing and decreasing the duration of delirium. Now we have more beds available. They don't board in the ED as long. They get up to the floor. They get out to home. This throughput is so much easier, which now opens up the staff to be able to provide better care for those patients that stay.

So such a complicated web, but it's important to know what we're talking about and know about the root causes of this prevalent problem in our system. If people are wanting to help support the advocacy and get involved with this, what do you recommend that they do? I think the biggest thing that I recommend is getting involved with your professional organization. I am heavily involved with the American Association of Critical Care Nurses. That is what led me here today to talking to you and

Honestly, just sending out an email to reach out to them, which is what I did, opened up many, many doors for me to be able to get into advocacy as well as open up a lot of doors for what's already being done and for me to look into all the research and various advocacy things that are happening. So that's definitely the avenue I encourage everyone going down. And there's a bunch of different organizations out there doing a lot of different things. But

looking into your, whether it's the Emergency Nurse Association, American Association of Critical Care Nurses. I know there's associations for all different types of nursing, and I know there's workplace violence stuff happening in all of those different areas. So I think that's the biggest thing. And then the second thing is, is just ask the question, ask the question at the institution that you work at, hey, what,

what are we doing here? You know, how can I get involved? And if there's not a lot going on, maybe, you know, bring a few ideas and, you know, come go get some ideas from your professional organization and kind of pitch those ideas. I think there's a lot of really easy things that can be done, but it just takes a little research to find out what's going on out there. Thank you so much. And I think in the oblivion about delirium and

Workplace violence, I think it's important that revolutionists bring this education to their organizations to say, look at what's happening. Even use case studies. So when you see it, write down that example. Obviously keep it HIPAA compliant, but write down what the patient was there for, their course of action. Tie in for your leadership, how delirium played into that situation, how mismanagement exacerbated it.

show the opportunities for improvement. And I think that's really helpful in making it not just about numbers. Obviously, we'll put citations in the show notes. So you'll have access to the big research, but show specific examples in your facility to help the entire hospital come together and play as a team to minimize the risks for everyone involved. Kelsey, thank you so much for coming on. Thank you for everything that you're doing to improve safety in our workplace environments. And I look forward to seeing what you get done. Yeah, thank you so much, Callie. I really appreciate it.

To schedule a consultation for your ICU, as well as find supportive resources such as the free e-book, case studies, episode citations, and transcripts, please check out the website, www.daytonicuconsulting.com.