How working with family members can improve care in the ICU

Published in the December 2005 issue of Today’s Hospitalist

Can hospitals improve outcomes in their ICUs by paying more attention to patients’ family members? The creators of a new initiative think the answer is yes, and they are gathering data to prove their point.

The thinking behind the initiative, known as the critical care family assistance program, is simple: By working more closely with the family members of ICU patients, hospitals encourage these all-important decision-makers to get more involved in their loved ones’ care.

Studies have shown that the strategy raises satisfaction levels of not only patients and family, but of nurses and physicians working in the ICU. Some critical care experts suspect that the program may even ultimately reduce these patients’ length of stay.

“We have known that ICUs have been tremendous for the critically ill,” says Robert McCaffree, MD, chief of staff at the Oklahoma City VA Medical Center, one of two hospitals that tested the program, “but families have been left out of the loop, other than for routine communication.”

Who are you treating?

The program, which is sponsored by the American College of Chest Physicians’ CHEST Foundation and is in place at eight U.S. hospitals, starts by challenging the longstanding assumption that ICUs’ main “clients” are their patients. Hospitals instead are urged to expand the defi nition of their clients to include patients’ family members.

“How families react to our environment doesn’t only impact the patient,” explains Jeffery Vender, MD, an anesthesiologist and director of critical care services at Evanston Hospital in Evanston, Ill., which was the other test site for the program. “Their perceptions of care and quality have immeasurable effects on whether the outcome is viewed as good or bad.”

A growing body of research is providing the data to back up that view. Several studies have proved what patients have known for a long time: The lack of communication between physicians and nurses and the family members of ICU patients contributes not only to increased anxiety during the illness, but grief at the time of death.

Other studies have found that family members’ stress limits their ability to both make decisions and help nurses and other staff care for the patient.

Making families more comfortable

To address those concerns, the critical care family assistance program takes a multi-pronged approach that focuses on improving communication with family members and changing the physical surroundings of the ICU.

At the Oklahoma VA, for instance, family members are encouraged to be present in the patient’s room during rounds. The entire multidisciplinary team that rounds on the patient can talk to the family and patient together.

“When that doesn’t work out,” says Dr. McCaffree, who is also president of the CHEST Foundation, “we try to set up special multidisciplinary conferences with the family.”

ICUs have also used the following strategies to improve communication and make family members more comfortable:

• Redesigned waiting rooms. Hospitals often?start by redesigning their ICU waiting rooms, which are frequently too small, cramped, dingy and generally uncomfortable.

  At the Oklahoma VA, the ICU waiting room now offers coffee, soft drinks, snacks and “comfort kits” that contain basics like a toothbrush and razor. The hospital also created a play area for children, and it gives vouchers to family members to help defray the expense of hotels and taxis.

  At Evanston Hospital, the ICU added a consultation room to give family members some privacy to discuss recent news or make plans.

  Dr. Vender notes that some ICUs have put computers into their waiting rooms so family members can research their loved ones’ condition and treatment. Out-of-town family members can also use the computers to fi nd information about where to eat or stay near the hospital.

• Sleeping quarters. Dr. McCaffree says that some ICUs have created sleeping rooms to give families a quiet place to get some rest. The Oklahoma VA, for example, converted a residents’ sleeping area that was rarely used into sleeping space for family members.
• Beepers for patients. To reassure family members that they won’t miss anything if they decide to get some shut eye, some ICUs now give beepers to family members. They can eat or sleep without worrying that they’re going to miss a chance to talk to a physician. “Hospitals have to pay for this,” Dr. McCaffree says, “but it is less expensive than you think.”
• Around-the-clock visiting hours. Both Drs. Vender and McCaffree say it’s critical to eliminate offi cial visiting hours for ICU patients. Setting limits on visiting hours, even if they’re not enforced, only increases families’ stress levels.
• Pet therapy. While some hospitals are offering massage or music therapy to relax family members, the Oklahoma City VA is trying something a little more unusual: pet therapy. Animals aren’t allowed into the patient’s room, but they can keep families company in the waiting room.

Promising results

After examining the program, several studies in the September 2005 issue of the journal CHEST reported promising results.

In one study, researchers found that the program improved family members’ perceptions of safety, helped them better understand information, and decreased patient anxiety. Families reported that they felt like they had been more involved in decision-making.

Dr. McCaffree says that ICUs participating in the program are currently analyzing length of stay to determine if their efforts have produced any differences. While those data have not been analyzed, he thinks they will show that the program reduces length of stay.

“I think it helps the patients to know that the family is being care for,” Dr. McCaffree explains, “so the patient can focus simply on his or her own task, which is trying to get well.”

While the program is designed primarily to help the family members of ICU patients, the program can also have an enormous impact on clinical staff. One of the articles in CHEST found that nurses and doctors perceived more collaboration among ICU team members and hospital departments, and that general staff thought communication, care and treatment were all improved.

Dr. Vender says that the program can also improve nurse satisfaction and possibly reduce nursing turnover. When families go wanting for information, he says, that creates stress for nurses.

“If families have good communication with nurses, the comfort level goes up, nurse confidence goes up, and the stress of a tenuous relationship goes down,” he explains. “This impacts how nurses feel about taking care of the patient.”

Dr. Vender says that adopting the critical care family assistance program is not very costly or difficult, but it does require a dramatic change in the mindset of many doctors and hospitals “an acceptance “that the family is part of the care process.”

Once that happens, he says, “behavior changes, and it sticks. The environment gets better, and it stays better.”

Deborah Gesensway is a freelance writer who reports on U.S. health care from Toronto, Canada.