Partial liberalization of visiting policies and ICU staff: a before-and-after study

Perceptions and preferences about family visitation restrictions and psychological distress among critical care clinicians in Brazil: results from a national survey

OBJECTIVE

To explore the perceptions of healthcare workers in the intensive care unit about family visitation policies and to examine their impact on healthcare workers' psychological distress.

METHODS

We disseminated an electronic survey to interdisciplinary healthcare workers via the Associação de Medicina Intensiva Brasileira during Brazil's most severe peak of COVID-19 (March 2021). We assessed perceptions of and preferences for family visitation policies and measured healthcare worker distress, including burnout, depression, anxiety, irritability, and suicidal thoughts using validated scales. We conducted multivariable regressions to evaluate factors associated with healthcare worker distress, including family visitation policies and healthcare workers' concerns.

RESULTS

We included responses from 903 healthcare workers: 67% physicians, 10% nurses, 10% respiratory therapists, and 13% other. Most healthcare workers reported that their hospitals allowed no family visitation (55%) or limited visitation (43%), and only 2% reported allowing unlimited visitation. Most believed that limiting visitation negatively impacted patient care (78%), and 46% preferred allowing more visitation (which was lower among nurses [44%] than among physicians [50%]; p < 0.01). Approximately half (49%) of healthcare workers reported that limited visitation contributed to their burnout, which was lower among nurses (43%) than among physicians (52%), p = 0.08. Overall, 62% of healthcare workers reported burnout, 24% reported symptoms of major depression, 37% reported symptoms of anxiety, 11% reported excessive alcohol/drug consumption, and 14% reported thoughts of hurting themselves. In the multivariable analysis, family visitation policies (limited visitation versus no visitation) and preferences about policies (more visitation versus same or less) were not associated with psychological distress. Instead, financial concerns and reporting poor communication with supervisors were most strongly associated with burnout, depression, and anxiety.

CONCLUSION

Half of healthcare workers self-reported that limited family visitation contributed to their burnout, and most felt that it negatively impacted patient care. However, family visitation preferences were not associated with healthcare worker distress in the multivariable regressions. More physicians than nurses indicated a preference for more liberal visitation policies.

Care Beyond Cure: Humanizing the Intensive Care Unit Journey

How to cite this article: Chacko B. Care Beyond Cure: Humanizing the Intensive Care Unit Journey. Indian J Crit Care Med 2024;28(10):901-902.

Healthcare Provider's Preferences on Open Versus Restricted Visiting Hours in Surgical Intensive Care Unit

BACKGROUND

The increasing consideration of open visiting hours in intensive care units (ICUs) has presented implementation challenges. Recognizing the invaluable insights of healthcare providers, this study aimed to assess their perspectives on the potential impact of altering ICU visiting policies on patient care.

MATERIALS AND METHODS

 In a single-institution, cross-sectional study, a five-point Likert survey was administered to healthcare providers working in a surgical ICU to assess their perceptions of open and restricted visiting hours. Descriptive statistics were used to analyze the responses.

RESULTS

Ninety-three healthcare providers participated, including nurses (53%), resident physicians (23%), and other healthcare professionals. The majority (81%) did not believe that open ICU visiting hours would enhance patient-centered care. Providers expressed concerns that open visitation could lead to increased provider stress (89%), physical barriers to patient access (80%), disruption in workflow (90%), and provider burnout (76%). Conversely, they perceived that restricted visitation would preserve patient privacy (87%), promote better healing for patients (64%), reduce provider stress (81%), and improve workflow (95%). Nurses were more likely than resident physicians to perceive that open ICU hours would alleviate familial stress (p=0.022). Additionally, both nurses and other healthcare providers recognized the potential for open ICU hours to improve communication between patient families and healthcare teams (p<0.05). Notably, there were no significant differences among providers in perceptions of the impact of open versus restricted visitation on provider stress, workflow, or other factors (p>0.05).

CONCLUSIONS

This survey reveals a negative perception of open ICU visiting hours among healthcare providers in a surgical ICU, with concerns that such a change could increase stress for both patients and providers. These findings underscore the potential challenges and negative impacts of implementing open visiting hours in this setting, emphasizing the need for careful consideration and further research to inform policy decisions and visitation practices.

The effect of visitation restrictions on ED error

EDs restricted visitors during the COVID-19 pandemic on the assumption that the risks of disease spread outweighed the psychological benefits of liberal visitation. But data suggest that beyond providing emotional support, family and caregivers can clarify history, improve patient monitoring, and advocate for patients-actions that can improve quality of care. Our objective was to assess whether removing visitors from the bedside contributed to errors in emergency care. We reviewed a database of medical errors covering visits from 11/15/17 to 7/30/22 at an urban, tertiary-care, academic ED for five types of error amenable to visitor intervention: inadequate history gathering, inadequate monitoring, falls, giving a medication to which a patient is allergic, and inappropriate medication dosing. These records were reviewed by two investigators to determine the likelihood visitor presence could have prevented the error. For those errors judged susceptible to visitor intercession, the number in each category was compared for the period before and after strict restrictions took effect. Our review found 27/781 (3.5%) errors in the pre-pandemic period and 27/568 (4.8%) errors in the pandemic period fell into one of these five categories (p = 0.29). Visitors prevented harm from reaching the patient in three of 27 pre-pandemic errors (11.1%), compared to 0 out of 27 peri-pandemic errors (p = 0.23). On review by two attendings, 17/24 (70.8%) errors that reached the patient in the pre-pandemic period were judged amenable to visitor intervention, compared to 25/27 (92.6%) in the pandemic period (p = 0.09). There were no statistically significant differences in the categories of error between the two groups; monitoring errors came the closest: 1/17 (5.9%) pre-COVID errors amenable to visitor intervention in these categories were monitoring related, whereas 7/25 (28.0%) post-COVID errors were (p = 0.16). While this study did not demonstrate a statistically significant difference in error between lenient and restrictive visitation eras, we did find multiple cases in the pre-COVID era in which family presence prevented error, and qualitative review of post-COVID errors suggested many could have been prevented by family presence. Larger trials are needed to determine how frequent and consequential such errors are and how to balance the public health imperative of curbing disease spread with the harm caused by restricting visitation.

S. S, Begum M, Chakraborty SR, Chowdhury H, Chowdhury MAR, Deb P, Akhter Farzana N, Ghose A, Harun Or Roshid M, Hoque Tipu MR, Hosain S, Hossain MM, Moinul Islam M, Kumar Tirupakuzhi Vijayaraghavan B, Mohsin M, Mund M, Nasrin S, Kumar Nath R, Nayak S, Pani N, Ahmmad Sarker S, Dondorp A, Tripathy S, Faiz MA. Understanding patient and family experiences of critical care in Bangladesh and India: What are the priority actions to promote person-centred care?

Patients' experiences in the intensive care unit (ICU) can enhance or impair their subsequent recovery. Improving patient and family experiences on the ICU is an important part of providing high quality care. There is little evidence to guide how to do this in a South Asian critical care context. This study addresses this gap by exploring the experiences of critically ill patients and their families in ICUs in Bangladesh and India. We elicit suggestions for improvements from patients, families and staff and highlight examples of practices that support person-centred care. This multi-site hospital ethnography was carried out in five ICUs in government hospitals in Bangladesh and India, selected using purposive sampling. Qualitative data were collected using non-participant observation and semi-structured interviews and analysed using reflexive thematic analysis. A total of 108 interviews were conducted with patients, families, and ICU staff. Over 1000 hours of observation were carried out across the five study sites. We identified important mediators of patient and family experience that span many different aspects of care. Factors that promote person-centred care include access to ICU for families, support for family involvement in care delivery, clear communication with patients and families, good symptom management for patients, support for rehabilitation, and measures to address the physical, environmental and financial needs of the family. This study has generated a list of recommendations that can be used by policy makers and practitioners who wish to implement person-centred principles in the ICU.

The effect of increasing duration of family members' presence on sleep status in patients with acute coronary syndrome in cardiac care unit: A randomized controlled trial

AIM

To investigate the effect of increasing duration of family members' presence on sleep status in patients with acute coronary syndrome (ACS) admitted to the cardiac care unit.

DESIGN

Randomized controlled trial.

METHODS

Ninety patients with ACS randomly assigned into two groups. No intervention was performed in control group. In the intervention group, the time of family members presence was changed from 1 h per day to 2 h per day from the second to the fourth day. Then, ST Mary's Hospital Sleep Questionnaire was completed by the patients every day during the study.

RESULTS

The patients in the intervention group had statistically significantly better sleep status during the course of intervention compared to the control group.

PATIENT OR PUBLIC CONTRIBUTION

The increasing duration of family members' presence can improve the sleep quality and quantity of ACS patients.

Levels of burnout and exposure to ethical conflict and assessment of the practice environment in nursing professionals of intensive care

BACKGROUND

Nursing professionals working in Intensive Care Units (ICU) are at high risk of developing negative emotional responses as well as emotional and spiritual problems related to ethical issues. The design of effective strategies that improve these aspects is determined by knowing the levels of burnout and ethical conflict of these professionals, as well as the influence that the practice environment might have on them.

OBJECTIVES

To analyze the relationship between levels of burnout, the exposure to ethical conflicts and the perception of the practice environment among themselves and with sociodemographic variables of the different intensive care nursing professionals.

METHODS

Descriptive, correlational, cross-sectional, observational study in an ICU of a tertiary level university hospital. The level of burnout was evaluated with the Maslach Burnout Inventory Human Services Survey scale; the level of ethical conflict with the Ethical Conflict Questionnaire for Nurses and the perception of the environment with the Practice Environment Scale of the Nursing Work Index. Descriptive and inferential statistics were performed. The association between categorical variables was analyzed using Fisher's exact chi-square test (χ2) RESULTS: 31 nurses and 8 nursing assistants were evaluated, which meant a participation rate of 82,93%. 31,10% of the nursing professionals presented signs of burnout, 14,89% considered that they work in an unfavorable environment and 87,23% presented a medium-high index of exposure to ethical conflict. The educational level (χ2=11.084, p=0.011) and the professional category (χ2=5.007, p=0.025) influenced the level of burnout: nursing assistants presented higher levels of this. When comparing the level of burnout with the environment and the index of ethical conflict, there were no statistically significant differences.

CONCLUSIONS

The absence of association found in the study between Burnout and ethical conflict with the perception of the practice environment suggests that personal factors may influence its development.

High-level burnout in physicians and nurses working in adult ICUs: a systematic review and meta-analysis

PURPOSE

The prevalence of burnout in intensive care unit (ICU) professionals is difficult to establish due to the variety of survey instruments used, the heterogeneity of the targeted population, the design of the studies, and the differences among countries regarding ICU organization.

METHODS

We performed a systematic review and meta-analysis examining the prevalence of high-level burnout in physicians and nurses working in adult ICUs, including only studies that use the Maslach Burnout Inventory (MBI) as a tool to evaluate burnout and involving at least 3 different ICUs.

RESULTS

Twenty-five studies with a combined population of 20,723 healthcare workers from adult ICUs satisfied the inclusion criteria. Combining 18 studies including 8187 ICU physicians, 3660 of them reported a high level of burnout (prevalence 0.41, range 0.15-0.71, 95% CI [0.33; 0.5], I2 97.6%, 95% CI [96.9%; 98.1%]). The heterogeneity can be at least in part explained by the definition of burnout used and the response rate as confirmed by the multivariable metaregression done. In contrast, there was no significant difference regarding other factors such as the study period (before or during the coronavirus disease 2019 (COVID-19) pandemic), the income of the countries, or the Healthcare Access and Quality (HAQ) index. Combining 20 studies including 12,536 ICU nurses, 6232 of nurses were reporting burnout (prevalence 0.44, range 0.14-0.74, [95% CI 0.34; 0.55], I2 98.6% 95% CI [98.4%; 98.9%]). The prevalence of high-level burnout in ICU nurses for studies performed during the COVID-19 pandemic was higher than that reported for studies performed before the COVID-19 pandemic (0.61 [95% CI, 0.46; 0.75] and 0.37 [95% CI, 0.26; 0.49] respectively, p = 0.003). As for physicians, the heterogeneity is at least in part explained by the definition used for burnout using the MBI but not by the number of participants. When compared, the prevalence of high-level burnout was not different between ICU physicians and ICU nurses. However, the proportion of ICU nurses with a high level of emotional exhaustion was higher than for ICU physicians (0.42 [95% CI, 0.37; 0.48] and 0.28 [0.2; 0.39], respectively, p = 0.022).

CONCLUSION

According to this meta-analysis, the prevalence of high-level burnout is higher than 40% in all ICU professionals. However, there is a great heterogeneity in the results. To evaluate and to compare preventive and therapeutic strategies, there is the need to use a consensual definition of burnout when using the MBI instrument.

Humanizing the intensive care unit experience in a comprehensive cancer center: A patient- and family-centered improvement study

OBJECTIVES

Improving family-centered outcomes is a priority in oncologic critical care. As part of the Intensive Care Unit (ICU) Patient-Centered Outcomes Research Collaborative, we implemented patient- and family-centered initiatives in a comprehensive cancer center.

METHODS

A multidisciplinary team was created to implement the initiatives. We instituted an open visitation policy (OVP) that revamped the use of the two-way communication boards and enhanced the waiting room experience by hosting ICU family-centered events. To assess the initiatives' effects, we carried out pre-intervention (PRE) and post-intervention (POST) family/caregiver and ICU practitioner surveys.

RESULTS

A total of 159 (PRE = 79, POST = 80) family members and 147 (PRE = 95, POST = 52) ICU practitioners participated. Regarding the decision-making process, family members felt more included (40.5% vs. 68.8%, p < 0.001) and more supported (29.1% vs. 48.8%, p = 0.011) after the implementation of the initiatives. The caregivers also felt more control over the decision-making process in the POST survey (34.2% vs. 56.3%, p = 0.005). Although 33% of the ICU staff considered OVP was beneficial for the ICU, 41% disagreed and 26% were neutral. Only half of them responded that OVP was beneficial for patients and 63% agreed that OVP was beneficial for families. Half of the practitioners agreed that OVP resulted in additional work for staff.

SIGNIFICANCE OF RESULTS

Our project effectively promoted patient- and family-centered care. The families expressed satisfaction with the communication of information and the decision-making process. However, the ICU staff felt that the initiatives increased their work load. Further research is needed to understand whether making this project universal or introducing additional novel practices would significantly benefit patients admitted to the ICU and their family.

The influence of nurse characteristics on practice skills and attitudes towards working with families in critical care: A regression analysis

OBJECTIVES

The study aimed to identify nurse characteristics that influence their self-perceived practice skills in working with families and their attitudes towards engaging families in adult and neonatal intensive care units.

RESEARCH METHODOLOGY/DESIGN

Secondary data analysis using a descriptive, cross-sectional design.

SETTING

An online survey was completed by 256 nurses from six adult intensive (73% response rate) and two neonatal intensive and one intermediate care unit (27% response rate) in a Swiss, university affiliated hospital.

MAIN OUTCOME MEASURES

Nurses' self-perceived practice skills in working with families were assessed with the "Family Nursing Practice Scale". Attitudes towards families were measured with the "Families' Importance in Nursing Care - Nurses' Attitudes Scale". Data were analysed with multiple linear regression models.

RESULTS

Prior education in family nursing significantly influenced nurses' self-perceived practice skills in working with families. Nurses' clinical speciality had a significant influence on their attitudes towards overall, and on the subscale "family as a burden". Neonatal intensive care nurses showed more open attitudes towards families overall, but perceived family more often as a burden than nurses in adult intensive care. Nurses' perceived skills and attitudes in family engagement significantly influenced each other.

CONCLUSION

The results suggest that nurses' prior education in family nursing and clinical speciality determine their ability to work with and engage families in critical care. Our study suggests that integration of family nursing engagement practices in critical care requires educational implementation strategies combined with culture change efforts.

Patient-Centered and Family-Centered Care in the Intensive Care Unit

Patient-centered and family-centered care (PFCC) is widely recognized as integral to high-quality health-care delivery. The highly technical nature of critical care puts patients and families at risk of dehumanization and renders the delivery of PFCC in the intensive care unit (ICU) challenging. In this article, we discuss the history and terminology of PFCC, describe interventions to promote PFCC, highlight limitations to the current model, and offer future directions to optimize PFCC in the ICU.

Family visitation policies, facilities, and support in Australia and New Zealand intensive care units: A multicentre, registry-linked survey

OBJECTIVE

The objective of this study was to describe family visitation policies, facilities, and support in Australia and New Zealand (ANZ) intensive care units (ICUs).

METHODS

A survey was distributed to all Australian and New Zealand ICUs reporting to the Australian and New Zealand Intensive Care Society Centre for Outcomes and Resources Evaluation Critical Care Resources (CCR) Registry in 2018. Data were obtained from the survey and from data reported to the CCR Registry. For this study, open visiting (OV) was defined as allowing visitors for more than 14 h per day.

SETTING AND PARTICIPANTS

This study included all Australian and New Zealand ICUs reporting to CCR in 2018.

MAIN OUTCOME MEASURES

The main outcome measures were family access to the ICU and visiting hours, characteristics of the ICU waiting area, and information provided to and collected from the relatives.

FINDINGS

Fifty-six percent (95/170) of ICUs contributing to CCR responded, representing 44% of ANZ ICUs and a range of rural, metropolitan, tertiary, and private ICUs. Visiting hours ranged from 1.5 to 24 h per day, with 68 (72%) respondent ICUs reporting an OV policy, of which 64 (67%) ICUs were open to visitors 24 h a day. A waiting room was part of the ICU for 77 (81%) respondent ICUs, 74 (78%) reported a separate dedicated room for family meetings, and 83 (87%) reported available social worker services. Most ICUs reported facilities for sleeping within or near the hospital. An information booklet was provided by 64 (67%) ICUs. Only six (6%) ICUs required personal protective equipment for all visitors, and 76 (80%) required personal protective equipment for patients with airborne precautions.

CONCLUSIONS

In 2018, the majority of ANZ ICUs reported liberal visiting policies, with substantial facilities and family support.

Communication and visiting policies in Italian intensive care units during the first COVID-19 pandemic wave and lockdown: a nationwide survey

BACKGROUND

During the first coronavirus disease 2019 (COVID-19) pandemic wave, an unprecedented number of patients with respiratory failure due to a new, highly contagious virus needed hospitalization and intensive care unit (ICU) admission. The aim of the present study was to describe the communication and visiting policies of Italian intensive care units (ICUs) during the first COVID-19 pandemic wave and national lockdown and compare these data with prepandemic conditions.

METHODS

A national web-based survey was conducted among 290 Italian hospitals. Each ICU (active between February 24 and May 31, 2020) was encouraged to complete an individual questionnaire inquiring the hospital/ICU structure/organization, communication/visiting habits and the role of clinical psychology prior to, and during the first COVID-19 pandemic wave.

RESULTS

Two hundred and nine ICUs from 154 hospitals (53% of the contacted hospitals) completed the survey (202 adult and 7 pediatric ICUs). Among adult ICUs, 60% were dedicated to COVID-19 patients, 21% were dedicated to patients without COVID-19 and 19% were dedicated to both categories (Mixed). A total of 11,102 adult patients were admitted to the participating ICUs during the study period and only approximately 6% of patients received at least one visit. Communication with family members was guaranteed daily through an increased use of electronic devices and was preferentially addressed to the same family member. Compared to the prepandemic period, clinical psychologists supported physicians more often regarding communication with family members. Fewer patients received at least one visit from family members in COVID and mixed-ICUs than in non-COVID ICUs, l (0 [0-6]%, 0 [0-4]% and 11 [2-25]%, respectively, p < 0.001). Habits of pediatric ICUs were less affected by the pandemic.

CONCLUSIONS

Visiting policies of Italian ICUs dedicated to adult patients were markedly altered during the first COVID-19 wave. Remote communication was widely adopted as a surrogate for family meetings. New strategies to favor a family-centered approach during the current and future pandemics are warranted.

Burnout and Associated Factors among Hospital-Based Nurses in Northern Uganda: A Cross-Sectional Survey

Background

Burnout is a public health problem that disproportionately affects nurses in sub-Saharan Africa because of the weak health systems that create an unconducive workplace environment. In Uganda, there is limited evidence on the burden of burnout among nurses in a manner that undermine advocacy and policy formulation. We aimed to assess the level of burnout and associated factors among nurses in northern Uganda.

Methods

This was a cross-sectional survey conducted among 375 randomly selected nurses from health facilities in northern Uganda. Data were collected using a self-administered questionnaire. Data analysis consisted of descriptive statistics and logistic regression at a 95% level of significance in SPSS version 25.

Results

Majority of the respondents were female 56.5% (n = 223). Nearly half, 49.1% (n = 194) of respondents had high levels of burnout, 36.2% (n = 143) reported average levels of burnout, and 14.7% (n = 58) reported low levels of burnout. Factors associated with burnout were age (AOR: 2.90; 95% CI: 1.28-6.58; p = 0.011), social support (AOR: 0.45; 95% CI: 0.22-0.94; p = 0.033), healthy eating (AOR: 0.06; 95% CI: 0.02-0.22; p < 0.001), workload (AOR: 0.31; 95% CI: 0.14-0.68; p = 0.004), and management responsibilities (AOR: 3.07; 95% CI: 1.54-6.12; p = 0.001).

Conclusion

Half of the nurses in northern Uganda experienced high levels of burnout. The Ministry of Health should consider recruiting more nurses to reduce workload and adjust working hours to prevent workplace-related burnout among nurses in the country.

The Psychological Impact on Relatives of Critically Ill Patients: The Influence of Visiting Hours

OBJECTIVES:

To identify the psychologic impact of admission to the ICU on the relatives of critically ill patients, the influence of coping, and the factors involved.

DESIGN:

We performed a cohort study with repeated measures evaluation using descriptive and comparative bivariate and multivariate analyses.

SETTINGS:

An adult ICU of a third-level complexity hospital.

PATIENTS:

The family members of patients (maximum of three per patient) staying longer than 3 days.

INTERVENTIONS:

Not applicable.

MEASUREMENTS AND MAIN RESULTS:

Psychologic impact was assessed using two subgroups of psychologic distress: anxiety (by the State-Trait Anxiety Inventory) and depression (by the Beck Depression Inventory). Satisfaction and coping were assessed by the Critical Care Family Needs Inventory and the Brief Coping Orientations to Problems Experienced Inventory, respectively. We included 104 family members; psychologic distress was high at admission (72% had anxiety, 45% had depression, and 42% had both) but decreased at discharge (34% had anxiety, 23% had depression, and 21% had both). The risk factors related to psychologic impact were severity (anxiety: Acute Physiology and Chronic Health Evaluation score ≥ 18 points: relative risk [RR], 2; 95% CI, 1–4; p = 0.03), invasive mechanical ventilation (anxiety: RR, 1.9; 95% CI, 1–3.6; p = 0.04), recent psychotropic medication use by relatives (depression: RR, 1.6; 95% CI, 1–2.9; p = 0.05), a restrictive visiting policy (anxiety: RR, 5.7; 95% CI, 2–10.4; p = 0.002), no emotion-focused coping strategy (anxiety: strategy < 11 points, RR, 6.1; 95% CI, 1.2–52; p = 0.01), and functional impairment (depression: Barthel index ≤ 60 points, RR, 7.4; 95% CI, 1.7–26.3; p = 0.01).

CONCLUSIONS:

The psychologic impact from admission to the ICU on family members is high. Visiting hours is the main modifiable factor to reduce the impact.

Family intervention for delirium for patients in the intensive care unit: A systematic meta-analysis

Delirium is one of the common manifestations of acute brain dysfunction in critically ill patients. We aimed to evaluate the effect of family intervention on reducing the delirium incidence in patients hospitalized in the intensive care unit (ICU). We searched electronic databases for randomized clinical trials, cohort, and before-and-after studies up to September 2021 using the MeSH terms ("family" OR "family caregiver") AND ("delirium"). A total of 6 studies including 4199 patients were analyzed. Compared to the control group, the risk of delirium was 24% lower in the family intervention group (OR 0·76 [0·67-0·86], P = 0.20, I² = 31%). Pooled data from two trials showed that family intervention was associated with fewer delirium days (SMD: -1.13, 95% CI: -1.91 to -0.34; P = 0.08; I² = 67%;). However, there were no significant differences between the two groups in the length of ICU stay, mechanical ventilation duration, and mortality (ICU stay days: MD: -0.62 days; 95% CI: -1.49 to 0.24; P = 0.14; I² = 72%; mechanical ventilation days: MD: -0.48 days; 95% CI: -2.10 to 1.13; P = 0.56; I² = 0%; mortality: OR: 0.68, 95% CI: 0.22 to 2.09; P = 0.08; I² = 67%). Current evidence supports the use of family intervention in reducing the delirium risk and delirium days in hospitalized ICU patients. However, its effects on reducing ICU stay length, ventilation duration, and mortality require further study. Future research should consider identifying the specific family intervention strategies and their duration.

Family Satisfaction in the Adult Intensive Care Unit: A Concept Analysis

Admission of patients to an intensive care unit is often a stressful event for family members. In the context of patient- and family-centered care, family satisfaction is recognized as a quality indicator of intensive care unit care. However, family satisfaction has not been consistently used or conceptualized in the literature. A modified version of Walker and Avant's method for concept analysis was utilized to examine the concept of family satisfaction in the adult intensive care unit. Antecedents, attributes, consequences, and empirical referents of family satisfaction are presented and implications for practice, research, and policy.

Prevalence and predictors of burnout among nurses during COVID-19: a cross-sectional study in hospitals in central Uganda

OBJECTIVE

To determine the prevalence of burnout and associated factors among nurses during COVID-19 in central Uganda.

DESIGN

A cross-sectional design.

SETTING

Nurse from one referral and four general hospitals. These were reception centres and cared for patients with COVID-19 in central Uganda.

PARTICIPANTS

395 nurses.

MAIN OUTCOME MEASURES

Burnout scores.

RESULTS

Of the total 395 participants, 65.1% (n=257) were female; 40% (n=158) had a diploma; 47.1% (n=186) were single; and 39.2% (n=155) had worked for 11-15 years. The results show that 40% (n=158), 41.77% (n=165) and 18.23% (n=77) reported high, average and low levels of burnout, respectively. The results show that the predictors of nurses' burnout were personal protective equipment (PPE) (OR: 7.1, 95% CI 4.08 to 12.31) and increased workload (OR 4.3, 95% CI 2.43 to 7.93).

CONCLUSION

This study of nurses working in hospitals dealing with patients with COVID-19 in central Uganda reported high rates of burnout, and it was associated with PPE and workload. Interventions like contracting new nurses to reduce workload, the WHO guidelines on PPE, adjusting working hours and ensuring hours of effective rest should be adapted.

The burden of the digital environment: a systematic review on organization-directed workplace interventions to mitigate physician burnout

OBJECTIVE

To conduct a systematic review identifying workplace interventions that mitigate physician burnout related to the digital environment including health information technologies (eg, electronic health records) and decision support systems) with or without the application of advanced analytics for clinical care.

MATERIALS AND METHODS

Literature published from January 1, 2007 to June 3, 2020 was systematically reviewed from multiple databases and hand searches. Subgroup analysis identified relevant physician burnout studies with interventions examining digital tool burden, related workflow inefficiencies, and measures of burnout, stress, or job satisfaction in all practice settings.

RESULTS

The search strategy identified 4806 citations of which 81 met inclusion criteria. Thirty-eight studies reported interventions to decrease digital tool burden. Sixty-eight percent of these studies reported improvement in burnout and/or its proxy measures. Burnout was decreased by interventions that optimized technologies (primarily electronic health records), provided training, reduced documentation and task time, expanded the care team, and leveraged quality improvement processes in workflows.

DISCUSSION

The contribution of digital tools to physician burnout can be mitigated by careful examination of usability, introducing technologies to save or optimize time, and applying quality improvement to workflows.

CONCLUSION

Physician burnout is not reduced by technology implementation but can be mitigated by technology and workflow optimization, training, team expansion, and careful consideration of factors affecting burnout, including specialty, practice setting, regulatory pressures, and how physicians spend their time.

Staff perceptions of family access and visitation policies in Australian and New Zealand intensive care units: The WELCOME-ICU survey

BACKGROUND

Family-centred critical care recognises the impact of a loved one's critical illness on his relatives. Open visiting is a strategy to improve family satisfaction and psychological outcomes by permitting unrestricted or less restricted access to visit their family member in the intensive care unit (ICU). However, increased family presence may result in increased workload and a risk of burnout for ICU staff.

OBJECTIVES

The objective of this study was to evaluate ICU staff perceptions regarding visiting hours and family access in Australian and New Zealand ICUs. Secondary outcomes included an evaluation of current visiting policies, witnessed events in ICUs, and barriers to implementing open visiting policies.

DESIGN

A web-based survey open to all healthcare workers in Australia and New Zealand ICUs was distributed through local, state-based, and national critical care networks. Open visiting was defined as ICUs open for visiting >14 h per day.

MAIN RESULTS

We received 1255 valid responses. Most respondents were nurses (n = 930, 74.1%) with a median critical care experience of 10 y. Most worked in open visiting ICUs (n = 749, 59.7%). Reported visiting hours varied greatly with a median of 20 h per day (interquartile range: 10-24 h). Open visiting was perceived as beneficial for the relatives, but less so for patients and staff (relatives: n = 845, 67.3%, patients: n = 561, 44.7%, staff: n = 257, 20.5%, p < 0.0001). Respondents from closed visiting units and nurses identified more risks from open visiting than other professional groups. Generally, staff preferred not to change from their current practice.

CONCLUSION

We report that staff perceived open visiting as beneficial for relatives, but also identified risks to themselves, including increased workload, a risk of burnout, and a risk of occupational violence. Reluctance to change highlights the importance of addressing staff perceptions when implementing an open visiting policy.

Why and how to open intensive care units to family visits during the pandemic

Since the lockdown because of the pandemic, family members have been prohibited from visiting their loved ones in hospital. While it is clearly complicated to implement protocols for the admission of family members, we believe precise strategic goals are essential and operational guidance is needed on how to achieve them. Even during the pandemic, we consider it a priority to share strategies adapted to every local setting to allow family members to enter intensive care units and all the other hospital wards.

Burnout Syndrome and Associated Factors in Intensive Care Unit Nurses

OBJECTIVE

to estimate prevalence and factors associated with Burnout Syndrome in intensive care nurses in a city in the state of Bahia.

METHODS

a cross-sectional, population-based study carried out with 65 intensive care nurses through a self-administered questionnaire, from July to November 2016, containing sociodemographic data, lifestyle, work characteristics. To define burnout syndrome, the Maslach Burnout Inventory was used.

RESULTS

Burnout Syndrome prevalence was 53.6%, an association was observed with age, tobacco consumption, alcohol use, weekly night shift hours, employment relationship, having an intensive care specialist title, number of patients on duty, monthly income and considering active or high-strain job.

CONCLUSION

the results of this study can contribute to expanding the discussion on stressful working conditions in Intensive Care Units.

Continuous Family Access to the Intensive Care Unit: A Mixed Method Exploratory Study

Introduction

Intensive care unit (ICU) visitation has traditionally been restrictive, primarily due to septic considerations and staff apprehension towards unrestricted visitation policy. However, ICU admission is stressful for patients and their families and the presence of family relatives at ICU patients’ bedside may help alleviate the same. The present study compares the viewpoints of healthcare workers (HCW) and patients’ family members regarding these two types of visitation policies.

Materials and methods

The initial assessment involved a qualitative investigation, based on an inductive grounded theory approach. Participant interviews were audiotaped, transcribed, manually coded, themes analyzed, and aggregate dimensions unfolded. Subsequently, a structured proforma filled by stakeholders and responses were coded as categorical variables (quantitative investigation). Their association with a continuous presence of family members was seen using univariate analysis (Chi-square test) and p <0.05 was considered significant. Satisfaction levels were rated on a Likert scale.

Results

Eighty-six stakeholders [group A: HCWs (15 doctors, 29 nurses), group B: patients (n = 18), and their relatives (n = 24)] were interviewed. While group A preferred restricted visitation policy (RVP), group B preferred unrestricted visitation policy (UVP). Quantitative data confirmed that HCWs (92.8% nurses and 85.7% doctors) were more satisfied with RVP and group B (92.3% relatives and 87.5% patients) with UVP. Group A (75.9% nurses and 93.3% doctors) therefore preferred RVP and group B (75% families and 66.6% patients) preferred UVP.

Conclusion

The patients and their families were more satisfied with UVP contrary to HCWs who were skeptical towards UVP and preferred RVP.

How to cite this article

Mahajan RK, Gupta S, Singh G, Mahajan R, Gautam PL. Continuous Family Access to the Intensive Care Unit: A Mixed Method Exploratory Study. Indian J Crit Care Med 2021;25(5):540–550.

Quality improvement of end‑of‑life decision-making and communication in the ICU : Effect on clinicians' burnout and relatives' distress

PURPOSE

End-of-life (EOL) decision-making is stressful. We conducted a quality improvement initiative to EOL decision-making and reduce stress for clinicians and patients' relatives.

METHODS

A before-after study running from 2010-2014 at four interdisciplinary intensive care units (ICU) in a German university hospital was performed. Between periods, a multifaceted intervention was implemented to improve timeliness, clinician involvement, and organisational support. Consecutive patients with severe sepsis and therapy limitations were included. Relatives were interviewed by telephone after 90 days to assess their psychological symptoms. Clinician burnout was assessed by staff surveys in each period.

RESULTS

Participation in the pre- and postintervention period was 84/145 and 90/159 among relatives, and 174/284 and 122/297 among ICU clinicians. Staff judged intervention elements as mostly helpful, but implementation of intervention elements was heterogeneous. From pre- to postintervention, relatives' risk of posttraumatic stress, depression and anxiety did not change (all p ≥ 0.464). Clinicians' risk of burnout increased (29% vs. 41%, p = 0.05). Relatives were highly satisfied in both periods (median of 9 vs. 9.2 on a 1-10 scale each). Attendings involved residents and nurses more often (both p ≤ 0.018). Nurses more often had sufficient information to talk with relatives (41% vs. 62%, p = 0.002). Time to first EOL decision as well as barriers and facilitators of EOL decision-making did not change.

CONCLUSIONS

The intervention may have increased involvement in EOL decision-making, but was accompanied by an increased risk of clinician burnout maybe due to lack of improving communication skills and organisational support. More research is needed to understand which interventions can decrease clinician burnout.

Prevalence of burnout among intensive care physicians: a systematic review

OBJECTIVE

We performed a systematic review to summarize the knowledge regarding the prevalence of burnout among intensive care unit physicians.

METHODS

We conducted a systematic review of the MEDLINE and PubMed® databases (last update 04.02.2019) with the goal of summarizing the evidence on burnout among intensive care unit physicians. We included all studies reporting burnout in intensive care unit personnel according to the Maslach Burnout Inventory questionnaire and then screened studies for data on burnout among intensive care unit physician specifically.

RESULTS

We found 31 studies describing burnout in intensive care unit staff and including different healthcare profiles. Among these, 5 studies focused on physicians only, and 12 others investigated burnout in mixed intensive care unit personnel but provided separate data on physicians. The prevalence of burnout varied greatly across studies (range 18% - 49%), but several methodological discrepancies, among them cut-off criteria for defining burnout and variability in the Likert scale, precluded a meaningful pooled analysis.

CONCLUSION

The prevalence of burnout syndrome among intensive care unit physicians is relatively high, but significant methodological heterogeneities warrant caution being used in interpreting our results. The lower reported levels of burnout seem higher than those found in studies investigating mixed intensive care unit personnel. There is an urgent need for consensus recommending a consistent use of the Maslach Burnout Inventory test to screen burnout, in order to provide precise figures on burnout in intensive care unit physicians.

Effect of Programmed Family Presence in Coronary Care Units on Patients' and Families' Anxiety

Introduction: Hospitalization of patients in the intensive care units always has negative consequences such as anxiety and concern for patients and their families. This study aimed to investigate the effect of programmed family presence in intensive care units on patients’ and families’ anxiety.

Methods: This was a quasi-experimental study conducted in Iran. The eligible patients and a member of their families were assigned into two groups (N = 80) through convenience sampling. The family members in the experimental group were allowed to attend twice a day for 15 minutes in a planned way beside the patient and contribute to their clinical primary care. In the control group, the family members had a strict limitation to visit their patients based on the usual policy. Anxiety in both groups at the beginning and on the third day of patient’s admission was measured, using Spielberger’s questionnaire. The data were analyzed with SPSS version13.

Results: The mean score of anxiety in the control group did not show significant difference in patients and in families, however it had decreased significantly in the experimental group after the intervention for both patients and families. The results showed that mean differences between the two groups was statistically significant in patients and families.

Conclusion: The planned presence of the family of patients in coronary care unit (CCU) played a crucial role in reducing the anxiety of patients and their family. Furthermore, it is recommended that strategies of visiting policy in intensive care units (ICUs) should be revised and the possibility be provided for the families’ planned presence and participation in the patient care.

Implementation of a flexible visiting policy in intensive care unit: A randomized clinical trial

BACKGROUND

Visitation is one of the most critical needs of patients in intensive care units (ICUs). Clinicians should enable a more flexible visitation policy to prevent the adverse effects of a restricted approach.

AIM AND OBJECTIVES

This study aimed at investigating the relationship between increasing visitation time and patients' physiological parameters in intensive units. Additionally, nurses' beliefs and attitudes towards visiting is examined in this research.

DESIGN

Parallel randomized clinical trial.

METHODS

This study was conducted in four general medical ICUs in Iran. In total, 60 patients and 57 nurses participated in this study. The patients' physiological parameters were measured at particular times in both groups. Moreover, the nurses responded to the questionnaire on beliefs and attitudes towards visitation in intensive units before and after the intervention.

RESULTS

Among all the physiological parameters, systolic and diastolic blood pressure and heart rate had a significant decrease within the normal range 10 and 30 minutes after visiting in the intervention group (P < .05), and nurses' beliefs and attitudes score were at the middle of the survey scoring range (0-120). However, no significant difference was found between nurses' belief and attitude score and intervention in any groups (P > .05).

CONCLUSION

The findings indicate that increasing visitation times can lead to a positive effect on the stability and balance of patients' physiological parameters.

RELEVANCE TO CLINICAL PRACTICE

A more flexible visiting policy can provide a therapeutic environment where not only patients' physiological disorders are minimised as much as possible but also a higher level of patients' health and satisfaction are reached.

Improving communication toward ICU families to facilitate understanding and reduce stress. Protocol for a multicenter randomized and controlled Italian study

OBJECTIVE

Families of ICU patients have a pressing need for information: they find themselves suddenly in a complex technical environment often because of a life-threatening illness of a loved one. Some evidence suggests that specific communication tools (like websites or brochures) could improve the experience of ICU families.

DESIGN

Randomized, multicenter, stepped wedge trial for large-scale assessment of the effectiveness of a multitasking intervention to improve communication with families of critically ill patients.

MAIN OUTCOME

correct understanding of the prognosis.

SECONDARY OUTCOMES

correct understanding of medical treatments, prevalence of anxiety, depression and post-traumatic stress symptoms in the first ICU week. Prevalence of PTSD 6 months from ICU discharge. Empathy and burnout among ICU staff. Prevalence of refusals for tissues/organ donation, and medical claims.

SUBJECTS

2100 ICU relatives of critically ill patients.

INTERVENTIONS

The intervention employs specific tools especially designed to raise the correctness of information and to improve the quality of communication: a website presenting the ICU world and justifying the relatives' emotions, with a webpage specifically dedicated to each participating ICU; a standard brochure; eight posters for the families' waiting room and a signboard for the ICU door.

MEASUREMENTS AND MAIN RESULTS

The study plans to assess these materials in up to 300 Italian ICUs that will participate, according to a five waves program, each one with randomized starting order. This way the effect of the intervention will be evaluated simultaneously.

CONCLUSION

This is an educational study, aiming to spread good medical practices, while also verifying their real effectiveness in a large number of ICUs.

TRIAL REGISTRATION NUMBER

NCT03438175.

Flexible Versus Restrictive Visiting Policies in ICUs: A Systematic Review and Meta-Analysis

OBJECTIVES

To synthesize data on outcomes related to patients, family members, and ICU professionals by comparing flexible versus restrictive visiting policies in ICUs.

DATA SOURCES

Medline, Scopus, and Web of Science.

STUDY SELECTION

Observational and randomized studies comparing flexible versus restrictive visiting policies in the ICU and evaluating at least one patient-, family member-, or ICU staff-related outcome.

DATA EXTRACTION

Duplicate independent review and data abstraction.

DATA SYNTHESIS

Of 16 studies identified for inclusion, seven were meta-analyzed. Most studies were rated as having a moderate risk of bias. Among patients, flexible visiting policies were associated with reduced frequency of delirium (odds ratio, 0.39; 95% CI, 0.22-0.69; I = 0%) and lower severity of anxiety symptoms (mean difference, -2.20; 95% CI, -3.80 to -0.61; I = 71%). Flexible visiting policies were not associated with increased risk of ICU mortality (odds ratio, 0.71; 95% CI, 0.38-1.36; I = 86%), ICU-acquired infections (odds ratio, 0.98; 95% CI, 0.68-1.42; I = 11%), or longer ICU stay (mean difference, -0.26 d; 95% CI, -0.57 to 0.05; I = 54%). Among family members, flexible visiting policies were associated with greater satisfaction. Among ICU professionals, flexible visiting policies were associated with higher burnout levels.

CONCLUSIONS

Flexible ICU visiting hours have the potential to reduce delirium and anxiety symptoms among patients and to improve family members' satisfaction. However, they may be associated with an increased risk of burnout among ICU professionals. These conclusions are based on few studies, with small samples and moderate risk of bias.

Effect of Organization-Directed Workplace Interventions on Physician Burnout: A Systematic Review

To assess the impact of organization-directed workplace interventions on physician burnout, including stress or job satisfaction in all settings, we conducted a systematic review of the literature published from January 1, 2007, to October 3, 2018, from multiple databases. Manual searches of grey literature and bibliographies were also performed. Of the 633 identified citations, 50 met inclusion criteria. Four unique categories of organization-directed workplace interventions were identified. Teamwork involved initiatives to incorporate scribes or medical assistants into electronic health record (EHR) processes, expand team responsibilities, and improve communication among physicians. Time studies evaluated the impact of schedule adjustments, duty hour restrictions, and time-banking initiatives. Transitions referred to workflow changes such as process improvement initiatives or policy changes within the organization. Technology related to the implementation or improvement of EHRs. Of the 50 included studies, 35 (70.0%) reported interventions that successfully improved the 3 measures of physician burnout, job satisfaction, and/or stress. The largest benefits resulted from interventions that improved processes, promoted team-based care, and incorporated the use of scribes/medical assistants to complete EHR documentation and tasks. Implementation of EHR interventions to improve clinical workflows worsened burnout, but EHR improvements had positive effects. Time interventions had mixed effects on burnout. The results of our study suggest that organization-directed workplace interventions that improve processes, optimize EHRs, reduce clerical burden by the use of scribes, and implement team-based care can lessen physician burnout. Benefits of process changes can enhance physician resiliency, augment care provided by the team, and optimize the coordination and communication of patient care and health information.

The Practice of Respect in the ICU

Although "respect" and "dignity" are intuitive concepts, little formal work has addressed their systematic application in the ICU setting. After convening a multidisciplinary group of relevant experts, we undertook a review of relevant literature and collaborative discussions focused on the practice of respect in the ICU. We report the output of this process, including a summary of current knowledge, a conceptual framework, and a research program for understanding and improving the practice of respect and dignity in the ICU. We separate our report into findings and proposals. Findings include the following: 1) dignity and respect are interrelated; 2) ICU patients and families are vulnerable to disrespect; 3) violations of respect and dignity appear to be common in the ICU and overlap substantially with dehumanization; 4) disrespect may be associated with both primary and secondary harms; and 5) systemic barriers complicate understanding and the reliable practice of respect in the ICU. Proposals include: 1) initiating and/or expanding a field of research on the practice of respect in the ICU; 2) treating "failures of respect" as analogous to patient safety events and using existing quality and safety mechanisms for improvement; and 3) identifying both benefits and potential unintended consequences of efforts to improve the practice of respect. Respect and dignity are important considerations in the ICU, even as substantial additional research remains to be done.

Effect of Flexible Family Visitation on Delirium Among Patients in the Intensive Care Unit: The ICU Visits Randomized Clinical Trial

IMPORTANCE

The effects of intensive care unit (ICU) visiting hours remain uncertain.

OBJECTIVE

To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium.

DESIGN, SETTING AND PARTICIPANTS

Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018.

INTERVENTIONS

Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation.

MAIN OUTCOMES AND MEASURES

Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory).

RESULTS

Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation.

CONCLUSIONS AND RELEVANCE

Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02932358.

Professional burnout among physicians and nurses in Asian intensive care units: a multinational survey

PURPOSE

Professional burnout is a multidimensional syndrome comprising emotional exhaustion, depersonalization, and diminished sense of personal accomplishment, and is associated with poor staff health and decreased quality of medical care. We investigated burnout prevalence and its associated risk factors among Asian intensive care unit (ICU) physicians and nurses.

METHODS

We conducted a cross-sectional survey of 159 ICUs in 16 Asian countries and regions. The main outcome measure was burnout as assessed by the Maslach Burnout Inventory-Human Services Survey. Multivariate random effects logistic regression analyses of predictors for physician and nurse burnout were performed.

RESULTS

A total of 992 ICU physicians (response rate 76.5%) and 3100 ICU nurses (response rate 63.3%) were studied. Both physicians and nurses had high levels of burnout (50.3% versus 52.0%, P = 0.362). Among countries or regions, burnout rates ranged from 34.6 to 61.5%. Among physicians, religiosity (i.e. having a religious background or belief), years of working in the current department, shift work (versus no shift work) and number of stay-home night calls had a protective effect (negative association) against burnout, while work days per month had a harmful effect (positive association). Among nurses, religiosity and better work-life balance had a protective effect against burnout, while having a bachelor's degree (compared to having a non-degree qualification) had a harmful effect.

CONCLUSIONS

A large proportion of Asian ICU physicians and nurses experience professional burnout. Our study results suggest that individual-level interventions could include religious/spiritual practice, and organizational-level interventions could include employing shift-based coverage, stay-home night calls, and regulating the number of work days per month.

Humanization of critical care-psychological effects on healthcare professionals and relatives: a systematic review

PURPOSE

To systematically review and evaluate the effects of humanized care of the critically ill on empathy among healthcare professionals, anxiety among relatives, and burnout and compassion fatigue in both groups.

SOURCE

MEDLINE, PsycINFO, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), and ProQuest Dissertations were searched from inception to 29 June 2017 for studies that investigated the effects of interventions with potential to humanize care of the critically ill on the following outcomes: empathy among critical care professionals, anxiety among relatives, and burnout and compassion fatigue in either group. We defined a humanizing intervention as one with substantial potential to increase physical or emotional proximity to the patient. Two reviewers independently selected studies, extracted data, and assessed risk of bias and data quality.

PRINCIPAL FINDINGS

Twelve studies addressing four discrete interventions (liberal visitation, diaries, family participation in basic care, and witnessed resuscitation) and one mixed intervention were included. Ten studies measured anxiety among 1,055 relatives. Two studies measured burnout in 288 critical care professionals. None addressed empathy or compassion fatigue. Eleven of the included studies had an overall high risk of bias. No pooled estimates of effect were calculated as a priori criteria for data synthesis were not met.

CONCLUSIONS

We found insufficient evidence to make any quantitative assessment of the effect of humanizing interventions on any of these psychologic outcomes. We observed a trend towards reduced anxiety among family members who participated in basic patient care, liberal visitation, and diary keeping. We found conflicting effects of liberal visitation on burnout among healthcare professionals.

Staff and family response to end-of-life care in the ICU

PURPOSE OF REVIEW

End-of-life (EOL) care can be stressful for clinicians as well as patients and their relatives. Decisions to withhold or withdraw life-sustaining therapy vary widely depending on culture, beliefs and organizational norms. The following review will describe the current understanding of the problem and give an overview over interventional studies.

RECENT FINDINGS

EOL care is a risk factor for clinician burnout; poor work conditions contribute to emotional exhaustion and intent to leave. The impact of EOL care on families is part of the acute Family Intensive Care Unit Syndrome (FICUS) and the Post Intensive Care Syndrome-Family (PICS-F). Family-centered care (FCC) acknowledges the importance of relatives in the ICU. Several interventions have been evaluated, but evidence for their effectiveness is at best moderate. Some interventions even increased family stress. Interventional studies, which address clinician burnout are rare.

SUMMARY

EOL care is associated with negative outcomes for ICU clinicians and relatives, but strength of evidence for interventions is weak because we lack understanding of associated factors like work conditions, organizational issues or individual attitudes. In order to develop complex interventions that can successfully mitigate stress related to EOL care, more research is necessary, which takes into account all potential determinants.

Study protocol to assess the effectiveness and safety of a flexible family visitation model for delirium prevention in adult intensive care units: a cluster-randomised, crossover trial (The ICU Visits Study)

INTRODUCTION

Flexible intensive care unit (ICU) visiting hours have been proposed as a means to improve patient-centred and family-centred care. However, randomised trials evaluating the effects of flexible family visitation models (FFVMs) are scarce. This study aims to compare the effectiveness and safety of an FFVM versus a restrictive family visitation model (RFVM) on delirium prevention among ICU patients, as well as to analyse its potential effects on family members and ICU professionals.

METHODS AND ANALYSIS

A cluster-randomised crossover trial involving adult ICU patients, family members and ICU professionals will be conducted. Forty medical-surgical Brazilian ICUs with RFVMs (<4.5 hours/day) will be randomly assigned to either an RFVM (visits according to local policies) or an FFVM (visitation during 12 consecutive hours per day) group at a 1:1 ratio. After enrolment and follow-up of 25 patients, each ICU will be switched over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome will be the cumulative incidence of delirium among ICU patients, measured twice a day using the Confusion Assessment Method for the ICU. Secondary outcome measures will include daily hazard of delirium, ventilator-free days, any ICU-acquired infections, ICU length of stay and hospital mortality among the patients; symptoms of anxiety and depression and satisfaction among the family members; and prevalence of burnout symptoms among the ICU professionals. Tertiary outcomes will include need for antipsychotic agents and/or mechanical restraints, coma-free days, unplanned loss of invasive devices and ICU-acquired pneumonia, urinary tract infection or bloodstream infection among the patients; self-perception of involvement in patient care among the family members; and satisfaction among the ICU professionals.

ETHICS AND DISSEMINATION

The study protocol has been approved by the research ethics committee of all participant institutions. We aim to disseminate the findings through conferences and peer-reviewed journals.

TRIAL REGISTRATION

NCT02932358.

[Burnout-a call for action]

BACKGROUND

Burnout is an emerging topic and has recently been the subject of a position paper of the US American Society of Critical Care Medicine.

OBJECTIVES

To give an overview over prevalence, causes, and relevance of burnout in intensive care unit (ICU) clinicians and point to potential prevention strategies MATERIALS AND METHODS: Narrative review.

RESULTS AND CONCLUSION

Burnout is a job-related state which results from long-lasting, permanent work overload when short spells of recreation, for instance during the weekend, are not effective to reduce exhaustion, vegetative symptoms, loss of efficiency, and depersonalization. Burnout may be due to (1) work-related factors, such as unmanageable workload and lack of appreciation by superiors and (2) personal factors, such as overly high demand and commitment. Surveys from France and Switzerland suggest that approximately one third to one half of ICU clinicians are affected. Large studies among hospital nurses show an increase in burnout. Burnout impairs patient safety and satisfaction, increases clinicians' intent to quit, and staff turnover.

CONCLUSIONS

Burnout is associated with a poor work environment. Burnout prevention or reduction is an important task which demands a multidimensional approach. The goal should be to improve the work environment, achieve good team collaboration, psychological safety, and inclusive leadership.

Effectiveness and Safety of an Extended ICU Visitation Model for Delirium Prevention: A Before and After Study

OBJECTIVES

To evaluate the effect of an extended visitation model compared with a restricted visitation model on the occurrence of delirium among ICU patients.

DESIGN

Prospective single-center before and after study.

SETTING

Thirty-one-bed medical-surgical ICU.

PATIENTS

All patients greater than or equal to 18 years old with expected length of stay greater than or equal to 24 hours consecutively admitted to the ICU from May 2015 to November 2015.

INTERVENTIONS

Change of visitation policy from a restricted visitation model (4.5 hr/d) to an extended visitation model (12 hr/d).

MEASUREMENTS AND MAIN RESULTS

Two hundred eighty-six patients were enrolled (141 restricted visitation model, 145 extended visitation model). The primary outcome was the cumulative incidence of delirium, assessed bid using the confusion assessment method for the ICU. Predefined secondary outcomes included duration of delirium/coma; any ICU-acquired infection; ICU-acquired bloodstream infection, pneumonia, and urinary tract infection; all-cause ICU mortality; and length of ICU stay. The median duration of visits increased from 133 minutes (interquartile range, 97.7-162.0) in restricted visitation model to 245 minutes (interquartile range, 175.0-272.0) in extended visitation model (p < 0.001). Fourteen patients (9.6%) developed delirium in extended visitation model compared with 29 (20.5%) in restricted visitation model (adjusted relative risk, 0.50; 95% CI, 0.26-0.95). In comparison with restricted visitation model patients, extended visitation model patients had shorter length of delirium/coma (1.5 d [interquartile range, 1.0-3.0] vs 3.0 d [interquartile range, 2.5-5.0]; p = 0.03) and ICU stay (3.0 d [interquartile range, 2.0-4.0] vs 4.0 d [interquartile range, 2.0-6.0]; p = 0.04). The rate of ICU-acquired infections and all-cause ICU mortality did not differ significantly between the two study groups.

CONCLUSIONS

In this medical-surgical ICU, an extended visitation model was associated with reduced occurrence of delirium and shorter length of delirium/coma and ICU stay.

Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis

BACKGROUND

Physician burnout has reached epidemic levels, as documented in national studies of both physicians in training and practising physicians. The consequences are negative effects on patient care, professionalism, physicians' own care and safety, and the viability of health-care systems. A more complete understanding than at present of the quality and outcomes of the literature on approaches to prevent and reduce burnout is necessary.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, PsycINFO, Scopus, Web of Science, and the Education Resources Information Center from inception to Jan 15, 2016, for studies of interventions to prevent and reduce physician burnout, including single-arm pre-post comparison studies. We required studies to provide physician-specific burnout data using burnout measures with validity support from commonly accepted sources of evidence. We excluded studies of medical students and non-physician health-care providers. We considered potential eligibility of the abstracts and extracted data from eligible studies using a standardised form. Outcomes were changes in overall burnout, emotional exhaustion score (and high emotional exhaustion), and depersonalisation score (and high depersonalisation). We used random-effects models to calculate pooled mean difference estimates for changes in each outcome.

FINDINGS

We identified 2617 articles, of which 15 randomised trials including 716 physicians and 37 cohort studies including 2914 physicians met inclusion criteria. Overall burnout decreased from 54% to 44% (difference 10% [95% CI 5-14]; p<0·0001; I²=15%; 14 studies), emotional exhaustion score decreased from 23·82 points to 21·17 points (2·65 points [1·67-3·64]; p<0·0001; I²=82%; 40 studies), and depersonalisation score decreased from 9·05 to 8·41 (0·64 points [0·15-1·14]; p=0·01; I²=58%; 36 studies). High emotional exhaustion decreased from 38% to 24% (14% [11-18]; p<0·0001; I²=0%; 21 studies) and high depersonalisation decreased from 38% to 34% (4% [0-8]; p=0·04; I²=0%; 16 studies).

INTERPRETATION

The literature indicates that both individual-focused and structural or organisational strategies can result in clinically meaningful reductions in burnout among physicians. Further research is needed to establish which interventions are most effective in specific populations, as well as how individual and organisational solutions might be combined to deliver even greater improvements in physician wellbeing than those achieved with individual solutions.

FUNDING

Arnold P Gold Foundation Research Institute.

Visita restrictiva / Visita no restrictiva en una unidad de paciente crítico adulto

Objetivo: buscar evidencia que responda a la pregunta ¿cuál es el impacto en el paciente, familia y personal de salud de visitas no restrictivas versus restrictivas? Método: revisión sistemática. Estrategia de búsqueda: 1993-2016 en Cochrane Library, Joanna Briggs, EBSCO,PubMed, CINHAL, Trip DataBase, con términos Mesh y palabras claves. Criterios de selección de artículos: revisiones sistemáticas,ensayos clínicos randomizados, no randomizados, cohortes, casos controles, estudios descriptivos correlacionales, UCI adultos, español e inglés. Recolección y análisis: selección inicial de 293 artículos, aplicando criterios de selección quedaron 13 artículos para análisis crítico.Calidad metodológica analizada con guías CASPe. Resultados: la visita no restrictiva no incrementa riesgo de infección, la ansiedad delpaciente es menor, la satisfacción de enfermeras es mayor, la presencia familiar ayuda a recuperación del paciente, la familia está más informada, satisfecha y con mejor conocimiento de situación. La frecuencia de complicaciones cardiovasculares es mayor en pacientes con visitas restrictivas. Conclusiones: las visitas no restrictivas en UCI no generan daño al paciente, por el contrario contribuyen a la recuperación de su salud física y emocional.