Care in the ICU
Tuesday, September 07, 2010
Healthcare Design of the Future
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.
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
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
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
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
Restricted visiting hours in ICUs: Time to
• 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
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
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.
Practical Guidance for Evidence-Based
ICU Family Conferences
• 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
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
Determinants and outcomes of patientcentered 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
Acuity Adaptable Rooms
Tuesday, September 07, 2010
Healthcare Design of the Future
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
Acuity Adaptable Room
• The solution to those problems is Acuity adaptable
• 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
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
– Chance of medication error, patient falls higher
because of patient flow
Design of Acuity-adaptable room
• Must have the capability to serve critical care patients as
well as recovering patients with their families – provide welldesigned 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
Design of Acuity-adaptable room
• Versatility
• Ergonomics
• Reduction in patient transfers
• Medication error rate down
• Lower patient fall rate
• Higher patient satisfaction
• Higher staff satisfaction – higher retention rate of nurses
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

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