Using the FS-ICU Instrument:
Understanding and Improving
Family Satisfaction in a Neuro ICU
David Y. Hwang, MD
Assistant Professor of Neurology
Division of Neurocritical Care and Emergency
Neurology
Yale School of Medicine
Jennifer Robinson, APRN
Yale-New Haven Hospital
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Lori Harmon, RRT, MBA
Director, Program Development
Society of Critical Care Medicine
Mount Prospect, IL
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David Hwang, MD
Assistant Professor of Neurology
Division of Neurocritical Care and
Emergency Neurology
Yale School of Medicine
Jennifer Robinson, APRN
Neuroscience ICU
Yale-New Haven Hospital
Adjunct Faculty
Yale University
Using the FS-ICU instrument:
Understanding and improving family satisfaction in a Neuro ICU
SCCM Project Dispatch Webcast 02/05/2014
David Y. Hwang, MD
Assistant Professor of Neurology
Yale Division of Neurocritical Care and Emergency Neurology
Jennifer Robinson, APRN
Yale Neuroscience
SLIDE 6
Disclosures
• David Y. Hwang, MD
–
–
–
–
American Brain Foundation Practice Research Training Fellowship
Remedy Pharmaceuticals, Inc. (GAMES-RP clinical trial site PI)
Bayer HealthCare (legal consulting)
Oxford University Press (book)
• Jennifer Robinson, APRN
– None
SLIDE 7
ngm.nationalgeographic.com
SLIDE 8
www.grassrootsmusic.org
SLIDE 9
Outline
• Importance of research on ICU family experiences
• Available survey tools for assessing family satisfaction
– Focus on FS-ICU
• Multidisciplinary team approach at Yale for collecting survey data
• Details of data collection setup, including troubleshooting problems
• Recent survey results from Yale-New Haven Hospital Neuro ICU
• Possible future directions
S L I D E 10
Importance of research on ICU family experiences
• Institute of Medicine 2001
report
– Recommendation for
healthcare delivery to be
“patient-centered”
– Shared decision making
– Coordinated care
– Physical/emotional support
– Culturally competent
IOM. National Academies Press 2001
S L I D E 11
Importance of research on ICU family experiences
Crit Care Med 2007;35:605
S L I D E 12
Importance of research on ICU family experiences
• As of October 2012, the
Affordable Care Act ties
consumer satisfaction to
hospital reimbursement
• Medicare withholds 1% of
normal reimbursement for a
“bonus fund”
• Hospital Consumer Assessment
of Healthcare Providers and
Systems (HCAHPS) survey
– Assesses patients’ perception
of care
– Scores factored into bonuses
www.washingtonpost.com/blogs/wonkblog
S L I D E 13
Importance of research on ICU family experiences
• Does family satisfaction with ICU care correlate with long-term
family outcomes?
– Caregiver burden for survivors
– Grief and bereavement for nonsurvivors
– Postintensive care syndrome (PICS-F)
•
•
•
•
Anxiety
Depression
PTSD
Acute Stress Disorder
Rothen et al. Curr Opin Crit Care 2010;16:623
Davidson et al. Crit Care Med 2012;40(2):618
S L I D E 14
Importance of research on ICU family experiences
• Despite existing controversies and uncertain influence of family
satisfaction on long-term patient and family outcomes:
– Satisfaction with medical care has become an important quality metric;
– Surveys such as HCAHPS typically capture satisfaction data from
patients themselves over the course of an entire hospital stay;
– Quality improvement in ICUs should ideally be guided by ICU-specific
information;
– ICU family satisfaction research has thus received increasing attention
over the past decade.
S L I D E 15
Rothen et al. Curr Opin Crit Care 2010;16:623
S L I D E 16
Available survey tools for assessing family satisfaction
• Critical Care Family Needs Inventory (CCFNI)
• Critical Care Family Satisfaction Survey (CCFSS)
• Family Satisfaction in the ICU (FS-ICU)
– FS-ICU 34
– FS-ICU 24
Kentish-Barnes et al. Crit Care Med 2009;37(10):S448
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Johnson et al. Crit Care Med 1998;26:266
S L I D E 18
Wasser et al. Crit Care Med 2001;29:192
S L I D E 19
FS-ICU
• Initially designed as a 34-item survey
• Half of items address satisfaction with overall care
• Half of items address satisfaction with the shared decision making
process
• Survey refined and revalidated in 2007 as a 24-item version
Heyland et al. J Crit Care 2001;16(4):142
Wall et al. Crit Care Med 2007;35:271
Heyland et al. Crit Care Med 2002;30:1413
www.thecarenet.ca
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FS-ICU
• Available for free on the Internet
• Items are mostly scored on a 5-point Likert scale
• Each item can be scored out of 100 points
• Some overlap with patient HCAHPS questions
• Wide use in the literature
– Multiple large observational cohorts
– Used as outcome instrument for intervention studies
Heyland et al. J Crit Care 2001;16(4):142
Wall et al. Crit Care Med 2007;35:271
Heyland et al. Crit Care Med 2002;30:1413
www.thecarenet.ca
S L I D E 21
FS-ICU
FS-ICU 24 items regarding general ICU care
Concern and caring of patient by members of ICU staff
Management of pain
Management of breathlessness
Management of agitation
Coordination of care
Competence of nurses
Competence of physicians
Amount of health care received in ICU
Interest in needs of family
Emotional support for family
Concern and caring of family members by members of ICU staff (courtesy, respect, compassion)
Frequency of communication with ICU nurses with family
Atmosphere in the ICU
Atmosphere in the waiting room
S L I D E 22
FS-ICU
FS-ICU 24 items regarding shared decision making
Frequency of communication by ICU doctors
Ease of getting information
Understanding of information
Honesty of information
Completeness of information
Consistency of information
Inclusion in decision making
Support during decision making
Control over the care
Time to address concerns and questions when making decisions
• 3 items for family members whose relatives died during ICU stay:
 Length of unnecessary prolongation of life
 Comfort
 Support by care team during family member’s death
S L I D E 23
FS-ICU
• Recent ICU interventional trial using the FS-ICU as outcome
instrument
• Qualitative analysis of write-in comments performed
• Recurring topics
– Timeliness of information received
– Appropriateness of communication in the patient care area
– Comportment (professional vs. rude communication)
Shaw, Davidson et al. Crit Care Med 2014;42(2):265
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Yale multidisciplinary team
• Approval by local IRB
• Multidisciplinary approach vital to success
–
–
–
–
–
Recruitment of diverse group
Low turnover of team
Core group of 5 members recruiting families
Led by physician and NP
Nursing leadership
• CNS
• ICU nurse manager
–
–
–
–
Physician assistant
Staff RNs
PA student
Unit business associate / secretary
S L I D E 25
Nuts & bolts of data collection
• Monthly reminders to group to sign up for “call schedule” (M-F)
• Recorded in group Google calendar account
• “On-call” responsibilities:
– Patient selection
– Enrollment
– Data collection
• Timeline
– Window for recruitment 24 hours prior and 8 hours after discharge
from ICU
• Family member selection
• Exclusion Criteria
– Admission <72 hours, unless made comfort measures
– Non English speaking
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Nuts & bolts of data collection
• Survey converted from paper to Google survey
• Only de-identified information online
• Family and patient demographics stored separately
• Automatically inputs results into Excel spreadsheet
• Expired patients collected separately
– Mailed letter detailing research study and paper version of survey
– ~1 month passed before contact
• Additional patient demographics of interest collected
–
–
–
–
–
Attending of record
Code status
Insurance
Education of family member
Diagnosis
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Challenges
• Workflow
– Time consuming
– Harder once patient transferred out of ICU
• Resources
– No dedicated research assistant
– Not funded
• Technical Issues
• Family Response
– ~55% response rate for survivors
– Interest
S L I D E 28
Benefits
• Fostering teamwork
• Involvement of bedside nurses in varied aspects of research
• Exploring our own strengths and weaknesses
– Waiting room
• Feedback from families
S L I D E 29
Neurocritical Care Society 2013 conference abstract
• Satisfaction with Emotional Support
Provided in a Neuroscience Intensive Care
Unit Among Families of Surviving Patients
with a Neurosurgeon Versus
Neurointensivist as the Attending of Record
S L I D E 30
NCS abstract chart 1: Most common diagnoses
Neurology
Neurosurgery
Intracerebral hemorrhage (37.8%) Subarachnoid hemorrhage (50%)
Ischemic stroke (24.3%)
Traumatic brain injury (10%)
Seizure (24.3%)
Subdural hematoma (10%)
S L I D E 31
NCS abstract chart 2: Patient demographics
Primary
Age in
Service
years
Length of
Stay in
Privately Insured
in %
Medicaid
Insured
days
p=0.004
in %
P=0.0001
(95% CI)
p=0.03
P=0.009
(SD)
(SD)
(95% CI)
Neurology
69 (14.7)
6.4 (4.4)
54.1 (±16.06)
10.8 (±10)
Neurosurgery
57.2 (12.8)
13.4 (8.9)
40 (±17.53)
33.3 (±16.86)
S L I D E 32
NCS abstract figure: Emotional support
• Families reporting complete satisfaction with emotional support
• p = 0.04
S L I D E 33
NCS abstract: Conclusions
• In our NICU, neurosurgery families are more likely to be
completely satisfied with the emotional support received from staff
compared to neurology families.
• Questions:
– Does a longer average length of stay allow NICU staff to build more of
a relationship with neurosurgery families?
– Do families feel more support with dual teams & attendings (NICU and
neurosurgery) following?
– Do neurosurgery families feel more support with a neurosurgery
attending who does not change weekly (vs. rotating intensivists)?
S L I D E 34
Influence of year-round neurointensivist coverage
p=0.0505
S L I D E 35
Influence of year-round neurointensivist coverage
p=0.0568
S L I D E 36
Families with prior ICU experience vs. new to ICU
Survey Variable
Prior
Exp
None
Frequency of communication by ICU doctors
65.0
69.2
Ease of getting information
82.9
84.6
Understanding of information
75.6
76.9
Honesty of information
82.5
80.8
Completeness of information
75.6
76.9
Consistency of information
65.9
65.4
Inclusion in decision making
70.7
61.5
Support during decision making
53.7
52.0
Control over the care
58.5
54.2
Time to address concerns and questions when making
decisions
94.4
92.0
Hwang DY, Robinson J, et al. Crit Care Med 2013;41(12):S830
S L I D E 37
Possible future directions
• Advantages of having ongoing ICU family satisfaction data
collection:
– Improved understanding of our local Neuro ICU at Yale
• Can help target ICU resources for quality improvement
– Approval by Institutional Review Board allows for ongoing analysis
and publication/presentation of observational data
– Built-in pre- and post-assessments for any future interventions or
change in practice that the team wishes to pursue
– Available pilot data for future grant applications
– Multidisciplinary ICU team building
S L I D E 38
Possible future directions
• Future analysis may focus more on surveys from families of those
patients who have been made comfort measures only in the Neuro
ICU
– Of note, prior analyses have suggested that families of patients who
pass away during ICU admission tend to report higher satisfaction
than those of patient patients who survive to discharge
Wall et al. Chest 2007;132:1425
• We welcome collaboration with other ICUs collecting FS-ICU data
– Increased observational power with larger number of surveys
– Please e-mail us!
S L I D E 39
Our team leaders at Yale
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•
•
Kelly Poskus, MS, RN
Cindy Bautista, PhD, RN
Jessica White, PA-C
Meghan McAnaney, RN
Anna Coppola, RN
Maria Koursaris, RN
Nathaniel Anderson, PA student
Lavenita Smith, BA
Kevin Sheth, MD, FCCM, FAHA
Emily Gilmore, MD
David Greer, MD, MA, FCCM, FAHA, FNCS
Evie Marcolini, MD
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Thank you!
David Hwang, MD
david.hwang@yale.edu
Jennifer Robinson, APRN
jennifer.robinson@yale.edu
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