Just imagine that family members could visit loved ones in the ICU whenever they want, for as long as they want, 24/7. Think it’s a great idea? You’ve probably had a family member in the ICU, or been a patient there yourself. Cringe at the very thought? You probably work in an ICU.
Sometimes what’s best for patients and family members is hard for staff. But that doesn’t mean it shouldn’t be done.
This was the idea behind an unusual challenge issued recently by Donald Berwick
, MD (IHI’s former president and CEO) to the hospitals currently enrolled in the Critical Care Settings domain of IHI’s IMPACT network. IMPACT is a community of change-oriented health care organizations working together to achieve new levels of quality.
“I believe that it is rational, humane, and even, to a responsible extent, evidence-based, to do away with visiting restrictions in critical care units entirely,” says Berwick.
So Berwick issued a challenge to the IMPACT member hospitals working specifically to improve critical care: “My plea is that at least some member hospitals execute a two-month trial of entirely open visiting in a Critical Care Unit.”
Berwick based his challenge on more than just his own feelings that family members can aid in patients’ recovery. In his challenge, he wrote: “After several years of work in the IOM ‘Chasm’ report context, ongoing instruction from true experts in authentic patient-centeredness, many exchanges with scholars in service industries, and study of leading-edge redesign efforts, I have come to believe strongly that visiting restrictions of any type in intensive care units are relics, which will be proven to be unnecessary, and potentially even harmful to the trajectory of healing, communication, and patient safety.”
Rising to the Challenge
At Geisinger Medical Center in Danville, PA, IMPACT team members rose to the challenge and implemented open visiting hours, cold-turkey, in August 2003. They have agreed to let IHI report periodically on their progress as they work through the issues and tweak the new program during the next year.
“We had actually implemented open visiting in the ICU a few years ago, but it didn’t go very well,” says Lani Kishbaugh, clinical nurse educator in Geisinger’s 16-bed shock and trauma ICU, and leader of the ICU visiting hours initiative at Geisinger.
“Some families would camp out in the ICU,” she says. “They were sometimes in the way. The doctors felt they couldn’t get their work done in there.” So they abandoned the practice, and went back to limiting visits to 30 minutes at 6 AM, 8:30 AM, noon, 2 PM, 6 PM, and 8:30 PM.
This time, however, the open visiting experiment is going much better, reports Kishbaugh. “We created an extensive communication program, educating both families and staff about what open visiting really means.” And, just as important, what it doesn’t mean.
Not a Free-for-All
According to Valerie Johnson, IHI project manager for Critical Care work, the most common barrier to open visiting in ICUs is staff resistance. “Doctors for the most part, but nurses too, worry that it will interfere with their ability to get things done,” she says. “But having an open visiting policy doesn’t mean you simply fling the doors open and stand back. There still have to be guidelines.”
Making and communicating guidelines is one of the reasons that the experiment is going better the second time around at Geisinger, says Kishbaugh. “We posted signs telling our visitors that we are testing open visiting, that we are trying to make it work to everyone’s satisfaction, including staff, patients and families.”
With the help of the doctor who was most resistant, staff drafted a handout for families spelling out some important guidelines, and trained nurses in how to talk with families about them. “We tell them we aren’t eliminating the rules about visiting,” says Kishbaugh. “We still remind them that patients who are recovering need rest and uninterrupted sleep. We still limit visitors to immediate family. We still limit the number of visitors. We still ask families to step out when nurses update the next shift on patients’ conditions or when a clinician asks them to. We have expectations about how families can use the open hours, and we are working on communicating those expectations effectively.”
Kishbaugh says that the nurses have been grateful for the training. “Some of our more experienced nurses have no problem explaining to families that their loved one needs rest and the best thing they can do sometimes is to go home. But our newer nurses weren’t as comfortable with it. So we are giving them some guidance on how to do it appropriately.”
Staff also helps families understand how and when to get information from the patient’s doctor. “They might see the doctor on the unit in the morning, and want to ask questions. The nurses tell families that the doctor is preparing the day’s care plan and that he or she will talk with them when the plan is set. They try to help the doctors keep on task and reassure the families that they will get the information they want.”
Giving Families Permission to Leave
One of the reasons some family members “camp out” under open visiting policies is that they are afraid that “something will happen” to the patient if they leave. “We need to reassure them that if their loved one’s condition should change, we would call them immediately,” says Kishbaugh.
To make this reassurance ironclad, staff tested the idea of giving families a beeper. “We had one family that was afraid to leave,” says Kishbaugh. “We gave them a beeper and they went home. Now we have five beepers for the unit, and if we have to get 16, one for each bed, we will. It’s worked really well.”
Sometimes the beepers are useful for a different reason. “We discovered we need to give some families permission to leave,” says Kishbaugh. “We had one woman who said that with open hours she felt obligated to be there all the time. We remind families that they need to take care of themselves too, that they shouldn’t feel guilty leaving. The beeper helps them feel connected and able to separate.”
Another common concern among ICU staff centers around having family members present when a patient experiences a crisis. At Geisinger, Kishbaugh says they had a recent experience that opened their eyes to the possibility that families can benefit from being with their loved ones even in the worst moments.
"We had a patient who had coded early in the morning, was resuscitated, and then coded again later that day,” says Kishbaugh. “The doctor and respiratory therapist agreed that the patient was unlikely to survive. The doctor invited the family in so they could see that everything possible was being done. There were 15 of us working on him. One nurse stood with the family to reassure them and answer questions, and they were very grateful they were there when he died. It went well.”
Kishbaugh says she conducted a survey among both staff and patients at the beginning of open visiting to assess their feelings, and she will do another survey after two months. Her findings so far reveal that families are happier than staff, but staff’s comments were generally constructive.
- Concern about privacy during procedures; some families pull the screen open to watch the procedure. (They now post an “Area Closed” sign on the screen during procedures.)
- Families listen to report and interrupt. (The unit now lists the times that staff is unavailable, including during shift changes.)
- Physicians bombarded with requests from families to speak with them; unable to get work done. (Staff educates families about when physician will be available.)
- Rules must be clearer: no eating and drinking in unit; no more than two visitors at a time; clinicians will limit visits if patient status warrants. (Guidelines clarified and written for families.)
- Like the open access to visit.
- Not clear on definition of “immediate family.”
- Not enough waiting space.
- Like the pager, needs to be numerical and alpha. A beep with no message made us nervous.
- Like to have set meeting times with doctor for status reports.
- Need to be educated as to why we cannot visit when clinicians impose limits.
Kishbaugh says they will take the information from the surveys and continue running PDSA cycles of change to address the concerns expressed. “We know we don’t just have one client,” she says. “We have a whole family of clients, and their needs are complex. We intend to address them.”