Wednesday, January 02, 2008

Bravo Brigham!

Liz Kowalczyk writes in the Boston Globe today about plans by Brigham and Women's Hospital to improve access to families of patients in its intensive care units. The Brigham is just completing a new building, and they have designed the ICU rooms to have sufficient space and amenities to permit family members to stay overnight. Here is the significant excerpt:

The rooms will be as big as 350 square feet - about double the size of the hospital's current rooms - and patients will be able to designate a relative or friend to stay with them each night, basically living alongside them in the room.

Doctors and nurses will encourage family members to help provide basic care, such as bathing and changing bandages, and allow designated individuals to remain in the room for most procedures, including removal of chest tubes, insertion of intravenous lines, and even resuscitations.

This is really an excellent step, and the Brigham deserves credit for including the possibility in the design of the new space -- but mainly for adopting medical rules and regulations that encourage this type of care.

In this regard, we are behind at BIDMC. As noted by a recent patient in a letter to me: "The ICU staff generally still sees family as outside of the direct care system.... The first night in the ICU was really awful, in that the visiting hours were strictly imposed, and we were allowed 2 people to visit her for five minutes every other hour. The nurse would look up at the clock when we entered, a kind of visual cue that she was counting. I’d strongly encourage (maybe, beg) for you to reconsider this policy in the ICU and throughout. I was told that the policy was in place for several reasons, but that the staff would never keep a family and a dying patient apart. I agree but think you are missing some wonderful energy and resources by placing limits in non-terminal situations."

So thanks to the Brigham for setting a great example. We are currently reviewing our own regulations to figure out what changes we should make. Likewise, in designing new ICUs and other rooms, we will be sure to make this a physical possibility. (By the way, the decision by the Brigham to expand the normal size of a room clearly adds costs. I think many would agree that this is money well spent, but I wonder if any of the insurers out there reading this would want to comment on how they feel about paying for this.)


Anonymous said...

Having spent 28 nights in a semi-intensive unit at BIDMC last year, I couldn't agree more that the Brigham's move is a great one. Having my wife with me, and other family members, made a massive difference to my experience, not to mention theirs.

I sure hope, though, that they provide real beds for the overnight guests. The recliners that are usually available are nasty excuses for a place to achieve rest.

Unknown said...

Paul, I came across this article in the NY Times, and thought you might like to read it if you haven't already.

I would love to see your thoughts on it.

Anonymous said...

Matt, I love Atul's writing. He is thoughtful and does a marvelous job.

On this article, I was a bit surprised at the regulatory issue he raised, and I have asked our folks to look into it.

Unknown said...

It just peaked my interest because there is so much push for evidence based medicine, it seems that this goes against just that.

I myself did quarters worth of Surg. Infection prevention sheet audits that we held physicians and other care givers to. Why would that be different? Core measures in itself would be just that.

Anonymous said...

There was a comprehensive article about the subject of Checkists, also by Atul Gawande, in the Jan 2 issue of the New Yorker.

I too, was wondering what you think of this and have been waiting for the opportunity to mention it in your Blog.

Anonymous said...

I thought Atul did such a good job in that article that I would have little to add. I'll ask some of our doctors who have made process improvements on central line infections and VAP and such to offer their thoughts.

Laurie said...

Having been a patient in the ICU as well as a family member visiting an ICU patient in a number of Boston hospitals (what can I say, I'm equal opportunity), I can't agree more that the new program at BWH is wonderful. I hope it spreads.

The fact that they're being proactive about the potential pitfalls--family not understanding what's going on, taking up too much of the nurse's time, etc--will be key to their success.

Now, on to read the Gawande article...

Anonymous said...

Regarding Gawande's article, I think the reaction goes beyond merely commenting, to the need for some action to ensure this sort of regulatory hardball doesn't set back years of work on patient safety efforts. It appears that Hopkins made some technical errors in filling out the various forms and grant applications, and for their trouble they got a very effective program (66% decline in central line infections) shut down. The feds clearly can't tell quality improvement from "human subjects research" and don't understand why obtaining informed consent on these situations is not only unnecessary but unachievable. I am composing a letter to the OHRP and suggest others do the same. The relevant documents and addresses are available on the comment thread on The Health Care Blog post called "Pilots use checklists; Doctors Don't". It's from late December so you'll have to scroll down to find it. I think the OHRP needs a deluge of protest here.

Anonymous said...

I am pleased to see this on your blog. I am a BIDMC ICU nurse and have 20+ years with you. I support family involvement and always have. I personally find it frustrating to "enforce" icu visiting limits for my patients' family member(s). I find myself apologizing to them.

Nurses are trained patient advocates. The patient comes first. Most patients want their loved ones near by. As a patient or family member, if I had a choice of hospitals to have surgery at, I would choose a hospital that offered such an arrangement. Who wouldn't?

I'm not saying this would be easy to implement or the right choice for all. It comes with pros and cons. As a nurse it's probably more work and a different approach to care.We would need to establish boundaries and involve the entire healthcare team for support. Perhaps even consider it on a case by case basis. Quite an adjustment to say the very least.(and yes, you'd have to spend the money to make the rooms bigger for saftey reasons alone)

But as for the patient, I can only see it as a win win experience regardless. I think that's really the bottom line here.

Anonymous said...

Thanks very much. Please talk with Mike Howell, who is working on ideas for new procedures.

Anonymous said...

Anonymous (9:50 a.m.) --

Sorry this response is a bit delayed. We are in the midst of some really major work on this, and would love to have you on the team as we figure out the right ways to center Critical Care around the patient and his/her family.

If you're interested, email me on the BIDMC system and I'll give you the full recruiting pitch in person.

- michael