Patient/Family-Centered Care in the ICU

1. Patient/Family-Centered Care in the ICU Tuesday, September 07, 2010 Healthcare Design of the Future

2. Introduction • Most critically ill patients lack decision-making ability, so • Family members must act as surrogates, so • Patient-centered care is family-centered care. • Approximately 20% of all deaths in the US occur during or soon after an ICU stay, and almost all involve family member surrogates. • Improved communications with family members can improve outcomes and reduce family member stress, depression, anxiety, and PTSD.

3. Effects of Child Visitation in the ICU • No studies like this before • 2 hypotheses • Change behavioral and emotional response of child • Change the emotional response of NHAFM • Control group  2 weeks  Experimental Group • Sig Diff on child perceived change scale

4. A Look at Critical Care Visitation • Literature review on open visitation policies • Families needs to be present • Difficult to visit during traditional hours • Patient can sleep • Balance family needs, improves satisfaction and communication, reduce cardiovascular complications • Posted vs. Actual  @ nurse discretion

5. Perceptions of 24-hour visiting policy • Goals: • Examine workers perceptions • Measure visiting times • Measure anxiety and depression in family • Outcomes • Only 2 visitors stayed overnight • Total visit time was 2 hours • Few signs of anxiety and depression • Policy only moderately interfered with care

6. Make LOVE, not war! • Leadership, Ownership, Values, Evaluation • Creating trust and respect in relationship between patients and health care providers • Open visiting hours • Additions to medical records • Training • Joint EOL decision • Positive trends in quality indicators, positive feedback from family

7. Restricted visiting hours in ICUs: Time to change • Caregiver staff concerns regarding liberalized ICU visitation hours misinformed; • Exposing patients to physiological stress • Nursing visits shown to increase patients stress levels • Interference of care • Family/ patient education and support structure • Exhaustion of family and friends • Open visitation beneficial to 88% and decreased anxiety in 65% of them Recommended: Systematic , unit-by-unit evaluation + feedback to inform liberal policies adopted within specific contexts.

8. Visiting preferences of patients in the ICU and in a CCMU* • Structured interview assessing: • Patients visiting preferences • What patients perceived as stressors and benefits of visiting • Patients’ perceived satisfaction with hospital visiting policies • Findings: • Patients mostly satisfied with flexible visiting hours in the ICU • Both thought that having visitors was neither stressful nor hindered their rest • Both preferred flexible visiting policies where they had the power to decide and tailor visiting hours • It is important to ensure that patient preferences are reflected in visitation policies. • Most ICUs have inflexible visitation policies * Complex care medical unit

9. Differences Between Families of ICU Survivors and Nonsurvivors Study findings: • Family members of deceased patients were more satisfied with the ICU experience than family members of survivors. • Groups were equally satisfied with the care received. • Two significant factors of difference: • Nursing care of the patient • Courtesy/respect shown to the patient • Clinician-family communication may be the most important factor driving family satisfaction in the ICU • ICUs are devoting extra effort to families of dying patients. • Additional care needs to be paid to families of surviving patients.

10. Practical Guidance for Evidence-Based ICU Family Conferences Recommendations: • Conduct family conference within 72 hours of admission to the ICU • VALUE 5-step approach V – Value family statements A – Acknowledge family emotions L – Listen to the family U – Understand the patient as a person E – Elicit family questions • Interdisciplinary involvement in family conferences • Spirituality and cross-cultural communications

11. Perception of Needs of Family Members Visiting and Nurses Working in the ICU • Four clusters of importance: • Emotional resources and support • Trust and facilitation of needs • Treatment information • Feelings • Survey asked family members and ICU nurses their opinions on the importance of various factors in satisfying family members needs • Importance placed by family members and nurses differed significantly

12. Determinants and outcomes of patient-centered care • Characteristics picked to illustrate patient-centered care; • Health knowledge • Patient asking questions • Chatting • Counseling • Patient lifestyle issues • Findings: • Patient-centered practice style is positively associated with higher patient self-reported health status, higher educational level and non smoking status. • Family physician-patient interactions exhibited more patient-centered characteristics than with the internists. • A higher average percentage of patient-centered care over the year was significantly related to lower total charges for medical care

13. Acuity Adaptable Rooms Tuesday, September 07, 2010 Healthcare Design of the Future

14. Why do we need a different kind of room? • Multiple transfers of patients • Patients admitted in non-equipped rooms because of lack of beds • Increased error rate • Patients demanding better comforts and health care • Insurance companies want to reduce the length of stay

15. Acuity Adaptable Room • The solution to those problems is Acuity adaptable rooms • A patient does not require to be transferred from one place to other but rather receives all the treatment at a single unit – regardless of the level of acuity • The acuity-adaptable model allows an individual patient room within a nursing unit to be reconfigured to meet the needs of any of the four acuity levels of nursing care: intensive care (ICU), stepdown, observation, and acute care

16. Universal room vs Acuity-adaptable room • Similarities • Rooms in both cases equipped with all the equipment • Differences • Patients still transferred from one unit to another • Distinction of units means nursing staff with varied training • Chance of medication error, patient falls higher because of patient flow

17. Design of Acuity-adaptable room • Must have the capability to serve critical care patients as well as recovering patients with their families – provide well-designed family areas • Conventional medical-surgical room is small (176-190 sq. ft). Acuity-adaptable rooms should be larger (at least 250-270 sq ft). Also provide acuity adaptable headwalls in each room • Offer privacy • Distributed nursing stations. Nursing supplies in each room

18. Design of Acuity-adaptable room • Versatility • Ergonomics

19. Results • Reduction in patient transfers • Medication error rate down • Lower patient fall rate • Higher patient satisfaction • Higher staff satisfaction – higher retention rate of nurses

20. Challenges in Acuity-adaptability • Cross-training staff – progressive as well as intensive care training to be given to all nurses • Collaboration, peer support and mentoring • Physician’s perception • Perceived workload • Equipment Cost • Physical design response • HCFA guidelines – variable rates for same patient in a single room not allowed.