Monday, January 26, 2009

ICU, but do I feel for you?


We've been thinking a lot about our intensive care units (ICUs) and how we could make them more comfortable, welcoming, and friendly -- not only for the patients, but more for their families. Last week, the three people here (Wendy McHugh, RN; Dr. Michael Howell; and Barbara Sarnoff Lee, our chief of Social Work) presented a report on this work in progress to our Board of Directors.

We serve 5500 adult ICU patients each year, in 9 separate units with 77 beds. Staff for these units comprise dozens of types of specialists and virtually every department in the hospital. The theory of the case for our working group is that the patient and family experience is an outcome that must be managed and improved. Thus, this is not a project. It is an attempt to understand the experience to great depth, looking at both quantitative and qualitative factors. We are aided in this process by a volunteer advisory group of patients and family members who have had ICU experiences.

A symbol of the "old way" is seen in the picture above: Hardly a welcome greeting! Another symbol was the existence of visiting hours in the ICUs. Why do they exist? Well, our working group decided to eliminate them. They decided that allowing loved ones to be in the ICU at all hours would actually be helpful to all parties. Since the patient is often unable to communicate well, who better to explain things to the medical staff and hear from the doctors during their rounds than a family member?

The group is also focusing on how to improve communication in this environment, making it more predictable and consistent. Another area of attention is how to improve the transition from the ICU to the regular floors, often a stressful period as the patient goes from continuous nursing care to more episodic care.

Since the usual patient satisfaction surveys don't really address the ICU experience, the team is also working with a survey designed for this audience of patients and families. In addition, Wendy engages families in real time to get their reactions to the environment and other issues.

I am sure the team would welcome thoughts from readers about your experiences in this kind of process improvement. Please post them here.

17 comments:

Ducketts said...

Hello there~

I have been following your blog for a little bit and this post struck a chord with me. I am what I like to call a professional patient. I have been in hospitals all my life and have spent many many months in ICU's. I was born with a very rare form of heart disease so it has kept me very close to the hospital bed. I have been going up to Boston for 35 or so years and am followed by Boston Children's Hospital.

As it pertains to ICU's I always felt that BCH has had more of a family feel and gave off less of a sterilized, drab sense. Often in most cases you only see a solid white or light grey color on the walls or floor but it really does help to put a splash of warm color there.

One aspect that truly helped my family and I in 2005 were small dormitory rooms nearby for family that needed to stay close. My father was allowed to stay and it really comforted me knowing he was there and eased his mind knowing that he could be by my bedside incase of an emergency. However I do believe at the end of each day it was first come first serve for these rooms.

I am aware of all hospital protocol but having a staff and a hospital willing to meet the needs of the patient and understand the desires of the families can ultimately do nothing but good for all parties involved.

I am scheduled to travel from NY to Boston the second week in February for a proceedure at BCH, hopefully I will be able to check the progress of your blog. I wish you all the best!

Take Care,

Chris

Logan said...

Paul,

Just my own two cents but I strongly encourage you to think very carefully about eliminating visiting hours. My mom is an RN who works a teaching hospital in upstate NY that went to open visiting hours. She works on the MICU and has described this policy as an absolute disaster. The open visiting hours have resulted in entire families coming in at all hours, and the nursing staff now finds themselves taking care of dysfunctional extended families. As my mom put it, "normal" families do not visit their loved ones with every extended relative and small child in toe at 3 AM. This is now a regular occurrence on their unit.

The staff have been harassed continually by staff, as well as having been threatened outright. In each case the administration has refused to intervene, in some cases passing it off as "grieving". However as my Mom notes ICU patients need rest and lots of care by the staff-neither needs the commotion of a dysfunctional family on the unit. Also, for what its worth, it creates a security nightmare-the hospital has had two fires on its floors since this policy went into affect.

I like the idea of patient-centered care but it seems to me the ICU is not subject to the same rules as the rest of the hospital. For the benefit of the patients and the safety of staff, I think its healthier to live visiting hours in place formally and let the nursing staff make the call after-hours. That way the hospital can have grounds for preventing the nightmare described above, and justifying the removal of certain individuals.

Thought I'd throw that in...

Paul RN said...

I am a nurse on the Medical ICU on the East Campus, the one in the photo. I have several thoughts regarding your post.

I work nights and having doors that require visitors to call in before entering is an important security measure by allowing us to know when people are entering our unit.

One potential problem with allowing all families open visitation 24/7 occasionally poses an issue with some families who do not cooperate with nursing staff, especially when asked to step out of a patients room during nursing interventions to protect the patients dignity.

In my experience most families I encounter are respectful, and they're presence helps communication and is therapeutic to the patient. I feel that we do try our best to support them.

Christian Sinclair, MD said...

The ICU can be a very intimidating place for patients and families. Open visitation policies are a very forward thinking idea that allows health care to shed a little bit of the technical disease oriented approach by elevating the role of relationships between family, patient and staff.

Making such a culture shift can have a profound impact on staff, especially if done without their input, so I would encourage you to make staff a partner in implementation and listen to their concerns. At the same time good research on this subject has been done and should be presented. See the bottom of the above link for many article that have cited it as well.

Open visiting hours should be complemented with a policy outlining the responsibilities of the visitors as well to help ensure the best care for their loved one. Any such information should be given in a way that includes the family as part of the team to make the patient better, as opposed to a patronizing tone that may alienate them.

I would also encourage you to think about how your palliative care teams are intertwined with your intensive care staff. Good cooperation between the two can lead to good quality of care for those who recover as well as those critically ill patients who die. Plus the added communication with a palliative care team may increase satisfaction scores as patient, families and staff feel more supported in difficult medical situations.

Maureen Bisognano said...

Paul,
Thanks for making these changes. As you know, my mother was cared for the amazing nurses and doctors at BIDMC near the end of her life, and I recall your visit to me during her final days. You asked "Is there anything I can do for your mother?" and I told you that was on her way to a peaceful death. You asked if there was anything you could do for me, and these changes will make a huge difference for ICU patients and families.
The families I met during our days and nights there were wonderful, grateful to the incredible staff and helpful in physical and psychological support for the patients. Though a rare problem may occur, you are right to design the system for the norm, and to ensure that families are welcome, invited and a part of the care team.
Many thanks! I visit hospitals all over the world, and one reliable measure of culture is the openness of the staff to include the family and the patient in the care decisions and processes.
Maureen Bisognano

Paul Levy said...

Christian,

To be clear, this is being driven, analyzed, and organized by the staff, not by senior management. We don't make changes to clinical processes at BIDMC from the top down.

Molly said...

I'm a social work intern from BC, working in the CVPR (w/ Tracey McHugh, LICSW) and in the ED/T-SICU/CC-6 (w/ Daniel Maher, LCSW). I think this is a great idea.

Also, you may find this NPR story interesting: http://www.npr.org/templates/story/story.php?storyId=94715147

Keep up the excellent work! I think your policy of transparancy should be lauded.

-Marion W. Merrick, MSW Intern

Jill Rose said...

I wrote an article on open ICUs in Inside Healthcare.http://www.inside-healthcare.com/content/view/1668/

Jill Rose, editor-in-chief
Inside Healthcare

Julie Rosen said...

Paul,

I think eliminating ICU hours is an excellent idea, providing it’s
done with a lot of staff input, as other readers have noted.

Other hospital departments, most notably maternity departments, have
long recognized that treating patients’ families well is good
business, and maybe even good medicine. It’s nice that other
departments are catching on to the fact that compassionate care should
extend to patients’ loved ones as well.

Julie Rosen
http://blog.healthtalk.com/bedside-manner/schwartz-center

Christian Sinclair, MD said...

Paul,

Thanks for the clarification regarding staff input. I figured you would include them, I just wanted it to be a more general point for all readers.

I am glad to see this has gotten a lot of responses too.

The one ICU I usually work at does have minor limitations during shift change (7a and 7p) which has been done for 'efficiency' of the work flow per staff.

Anonymous said...

As a BIDMC ICU Nurse, I fully support eliminating visiting hours. I've always felt awkward telling people they have to leave at a certain time and can't come back until noon the next day. The only reason I "enforced" it was to prevent families from splitting staff members and to provide consistency. However -- our ICU's need a TON OF WORK to make this work. The rooms are too small to support this. It is uncomfortable for family members. There is nowhere in the hospital they can sleep. We simply don't have enough chairs for them, let alone anything comfortable. The waiting rooms are pathetic. We barely have a kitchen for them to get water. Staff attitudes will be resentful towards this change at first. It needs to be rolled out with copious amounts of culture change in the units. For this to work, please, I beg, invest some money into renovating these rooms and units to make it practical to have increased family presence... and please, as the other nurse stated, make sure this is done in a safe way for the staff. Having a family member in an ICU can exacerbate any bizarre behaviors or intense personalities, and it puts us at extreme risk for family members to be able to waltz in at any time - and also threatens patient dignity depending on what situation they might walk in on.

Paul Levy said...

All good points that I am sharing with others.

Michael said...

Anonymous (from 11:38) --

All are good and important points … and very validating to see written down, since they are issues that we’ve identified and are (where possible) working to address. As one example, we're piloting ICU waiting room redesign and improvement now -- a process that has involved patients, families, nurses, and docs. In addition, as someone who works overnights in our ICUs myself, I'm particularly attuned to the issue of safety for staff that you've raised, and we're trying to do this in as thoughtful and careful a way as possible.

(Incidentally, if you'd like to help create the way we roll this out, just send me a note on the BIDMC email system. Would love to have your help.)

Thanks again for your thoughtful comments,
- michael

________________
Michael Howell, MD MPH
Director, Critical Care Quality

Jeff said...

Paul,

This subject of open visitation in the ICU's is near and dear to my heart. Having been a nurse manager in our Medical ICU for over six years, I have personally been involved with hundreds of critically-ill patients and their families.

Many years ago, we had limited visiting hours. I had strong feelings about asking family members to leave the unit, but adhered to it simply because it was the policy. Even though family and friends were overtly upset, we asked them to leave, and I truly hated doing it.

It was not until our new Chief Nursing Officer held an ICU manager/director meeting, that we had the opportunity to hear all sides of this subject. Our CNO had a strong feeling against visiting hours. She asked if any of us was aware of the origin of "visiting hours" in general, and stated that the concept originated in the penal system, whereby prisoners would only be allowed visitation at very limited intervals. Looking at it from that perspective was truly eye-opening for us all, and brought an interesting viewpoint to a very important subject.

From that point forward, we all agreed that open visitation benefited everyone, most importantly the patient, and their family and friends. Many staff complained to me, in the following months, about visitors "being in the way". If procedures were necessary, we kindly asked family to wait outside the unit, which they agreed to do, however I quickly ushered them back in as soon as the procedure was completed. I noticed a completely different atmosphere in the unit, and observed a change in staff attitudes, as well. The one experience that solidified our decision for open visitation came from a patient who had been intubated for several weeks, and had eventually regained consciousness. He stated that he recalled an experience whereby his daughter spoke with him begging him to "get better". When the patient talked about this, a staff nurse stated she remembered that the patient’s daughter had driven to the hospital from college to visit him, and had arrived in the middle of the night. There was no better justification for our decision to welcome open visitation than this story of our patient and his daughter.

We now have open visitation throughout our entire hospital and, with the assistance of our security team, have never once experienced any untoward situations as a result of showing kindness and consideration to our patients and their loved ones.

Jeff

Bernard said...

Paul

I know this type of change is costly in many different ways. What you're really talking about is generally called User eXperience. How does it feel to people when they encounter an ICU situation. The UX for patients may be very different to the UX for their family members. Improving both, without compromising care, is probably a cost effective way to get better outcomes.

You might want to look at what Ideo has done in various healthcare settings to improve UX. Costly company to work with, but I don't think you can put a price on improvements in this area.

Michelle G. said...

I work in a 21 bed Medical ICU in the South. Several years ago our unit voted to become an "open" unit and I was one of the proactive nurses that wanted the signs removed and the doors open. Now I am second guessing myself and the benefits to the patients. These patients never have a moment to rest. Families are always at the bedside talking, parading church members, infants, and small children in and out of the unit at all hours of the night and day. When nurses are in rooms caring for patient #1, family members from #2 will walk right in and demand you come immediately to patient #2's bedside. These families are specifying which nurses may be permitted to care for their family members, simply because a nurse refused to give a medication the family wanted given and the patient had refused. Administration does not want to "upset" the family any more and acquiesces. Doctors are afraid to give a poor prognosis and will continue to provide advanced treatments and therapies on the dead for fear of litigation from families.
When some boundaries are removed it is perceived that no boundaries exist. This type of thought process has created very difficult patient/family/professional relationships. We are caring for more and more difficult families and our nurses are becoming burnt out. The patients need a reprieve to rest. Nurses need moments of uninterrupted to prepare medications, care for the other patients, and to simply chart. Notice I have not even mentioned to care for themselves because going to the bathroom is now seen as something that should not be done on your shift. It saddens me to say that because of these difficult situations. I will be looking to leave the ICU environment I once loved.
I hope your choice to open your unit has worked, but I would suggest relaxing the hours but still having some time in the afternoon where patients can find a quiet moment and the staff can breathe as well.

Paul Levy said...

Thanks, Michelle. I never heard of such problems in our place, but perhaps so.