Patient/Family-Centered
Care in the ICU
Tuesday, September 07, 2010
Healthcare Design of the Future
Introduction
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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.
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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
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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
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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
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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
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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.
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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
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* 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.
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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
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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
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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
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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
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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
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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
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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
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Design of Acuity-adaptable room
• Versatility
• Ergonomics
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Results
• Reduction in patient transfers
• Medication error rate down
• Lower patient fall rate
• Higher patient satisfaction
• Higher staff satisfaction – higher retention rate of nurses
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Challenges in Acuity-adaptability
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Cross-training staff – progressive as well as intensive care training to be given to
all nurses
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Collaboration, peer support and mentoring
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Physician’s perception
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Perceived workload
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Equipment Cost
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Physical design response
• HCFA guidelines – variable rates for same patient in a single room not
allowed.
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