Best Practices: Step by Step
Features
Written by Jill Rose   
Thursday, 31 January 2008
Best Practices: Step by Step - Health Executive - RedCoat Publishing
The process of opening up the ICU to families may not be easy, but our experts say the benefits far outweigh the challenges.
For some ICUs, opening up to families is the next logical step in patient care; for others, it’s a huge leap. For all hospitals, regardless of where they are in making this transition, the question is one of value. In other words, who benefits and how much?

For Phil Scavotto, director of nursing at Maine Medical Center’s special care unit, the answer is clear: both patients and nursing staff benefit tremendously from having families present. Yes, there is a cultural shift that has to take place, and yes, cultural shifts can be tricky, but Scavotto is unequivocal. “The days of locking the door and keeping the public out are coming to an end,” he said.

RN Judy Davidson, a clinical nurse specialist at Scripps Mercy Hospital in San Diego, and lead author of the Society of Critical Care Medicine’s guidelines for family support, agrees. “When families are happy in the ICU, it increases satisfaction, and satisfaction is known to have an affect on staff morale and retention, as well as on marketshare and return customers,” she said. “Family support is important for the family from an ethical and moral standpoint, but there’s also a business case for it.”

No phone on the wall
Scavotto has years of experience with open ICUs, having worked in MMC’s pediatric ICU for 12 years, followed by nine years in the center’s 32-bed mixed use special care unit (both adult and pediatric).

Families have always been welcome in the ICU. “There’s been no phone on the wall since I’ve been here,” Scavotto said. But before 2000, visits to adult ICU patients were restricted to two immediate family members for five-minute visits. (The pediatric ward was less restricted, allowing open visitation for parents and grandparents.)

Since then, the hospital has worked on policies designed to better accommodate families, and in 2005, the hospital began adopting the Safe Patient Family Centered Care model (SPFC). A 40-person SPFC committee meets monthly to discuss and issue recommendations; from there, a team from each unit determines how the recommendations can be implemented in their work environment.

For example, patients are now encouraged to ask questions like “Have you washed your hands today?” and “What meds are you giving me?” Although initial reactions by nurses to these types of shifts have been mixed, Scavotto said they are part of the hospital’s overall mission to provide better service and are becoming more accepted.

“If you brought your car to a mechanic, wouldn’t you ask questions? Why wouldn’t you do that here? If people don’t ask questions, that should be a red flag,” he said.

One of the biggest issues is how to handle family members when an ICU patient is having an acute medical crisis. MMC has addressed this through training and a family-support program.

“The nurses asked, ‘If I have a patient crashing and I’m working to start a drip, how can I be family centered?’” said Scavotto. “The answer is that you say, ‘I need to focus on your loved one right now. I’m not trying to be rude, but I need you to step out or be over there, and I will address your questions as soon as I’m finished.’”

In addition, the hospital’s research into family presence during codes has shown that it’s often beneficial. If family members want to be present during a code, they receive a pager that summons them and a family-support person to the patient room.

“You need someone in the room to explain what’s going on. It can’t be the person passing meds to the bedside,” Scavotto said, noting that social workers, nurses, and nursing supervisors take shifts as family-support personnel.

Levels of maturity
In February of last year, the Society for Critical Care Medicine released 43 recommendations related to support of family in patient-centered ICUs (available at www.sccm.org). Lead author Judy Davidson acknowledged the large number of recommendations can be daunting at first but said every hospital has a different level of maturity in this area.

“If the guideline team picked five or six things hospitals had to do to be in compliance, and they were things a particular hospital already did well, they would think they were done and not look at improving family support,” she said.

Davidson recommends creating a staff/physician survey to rank importance of the 43 recommendations, narrowing the list down to one from each subsection, presenting the shortened list to staff and physicians as potential items for improvement, and holding a vote to choose two or three to work on first. She noted that at Scripps Mercy Hospital, the process of surveying staff led to practices changing before a plan was even in place.

“People start doing things differently just because they’ve been exposed to it and talking about it. They may start changing their own practice, even if the hospital doesn’t change policy,” she said. For example, Davidson saw an increase in family presence during rounds. “I didn’t measure it, but I could see it,” she said.

Two things Davidson has observed in increasing family ICU access are the need for a detailed security policy and a potential need for two waiting rooms. “Once people knew I was coordinating this effort, they began to come talk to me, and I received a consistent message from nurses that security of the staff is critical if you’re going to open up visiting on the night shift. The lesson learned is that executives must be sure to include the security department in these discussions.”

As for waiting rooms, Davidson said as she interviewed family members about their needs in the ICU, she learned it may make sense for some hospitals to have a regular waiting room that can accommodate the large groups (often including children) that are important for certain cultural groups, and a quiet waiting room for those who would otherwise be overwhelmed by large-group activity.

Davidson also said that while newer ICUs are being built to physically accommodate families (and some older ICUs are being renovated for this purpose), it’s not absolutely critical. “I worked in a tiny ICU in the past. It had private rooms with walls, but they were very small, and we had 24-hour visiting. It’s not comfy, and you have some special issues with confidentiality, but you can make do.” (Floor plans for ICU designs are available from the Society of Critical Care Medicine.)

A boon to nurses
Davidson is conducting research on the effect of the family’s ICU experience on the patient. “We know that between 30% and 80% of family members of critically ill patients can experience anxiety, depression, and even post-traumatic stress disorder as a result of their experience,” she said. “How we treat them and how we care for them as part of the healing process has a significant impact on their ability to care for their loved one later.”

She noted that most critically ill patients need long-term care after their ICU stay, and whoever is the next of kin most likely has to provide that support. “Maintaining their health during the crisis by catering to their needs will enable them to better care for the patient at home. If they can’t care for them at home, they are likely to have to be readmitted.”

Scavotto agrees, saying the nursing staff can play a crucial role in helping family members understand the importance of taking care of themselves. “It helps for the nurse to say, ‘Your (family member) is stable. This would be a good time for you to rest or get outside and get some air.’ You start to build that trust relationship.”

A rested family member can also be a boon to the nursing staff. “We tell people to rest while they can because when the patient wakes up, they’re on.” Indeed, the hospital is beginning to take a page from the pediatric ICU. “The best thing for kids waking up from anesthesia is for them to smell their loved ones and have them snuggle them. Today, nurses often call the parent into recovery before a child wakes up to ease the transition. If we can change the culture from keeping parents out to asking them to come in, why shouldn’t we do the same with adults?”
 
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