Family Presence for Critically Ill Patients During a Pandemic

Multidisciplinary healthcare Professionals' attitudes towards family engagement in the adult intensive care unit

OBJECTIVES

Family engagement in the intensive care unit (ICU) is a crucial aspect of healthcare delivery, yet it remains an inconsistent practice and an understudied area of healthcare for adult patients in the ICU. This study aimed to explore the attitudes of healthcare professionals (e.g., registered nurses (RNs), physicians, pharmacists, respiratory therapists, social workers, and dietitians) on family engagement in the adult ICU and to elucidate factors that impact these attitudes.

METHODS

We used descriptive cross-sectional analysis to explore the attitudes of a sample of 90 healthcare professionals toward family engagement in the ICU for adult patients. Data were collected using the Families' Importance in Nursing Care-Nurses' Attitudes (FINC-NA) questionnaire. The data were analyzed using descriptive statistics and multiple linear regression.

MAIN OUTCOME MEASURES

Healthcare professionals' attitudes towards family engagement in the ICU varied across different professional roles and were associated with years of experience. Results demonstrated that physicians had the highest positive attitude score towards family engagement on the total attitude scale and the family as a resource.

IMPLICATIONS TO NURSING PRACTICE

Understanding the attitudes of healthcare professionals is a crucial step toward developing evidence-based interventions that can facilitate family engagement in care for adult patients in the ICU. Cultivating a partnership culture with patients' families in the ICU is crucial, but interventions are needed to enhance nurses' and other healthcare professionals' attitudes toward family engagement. Specialized training, resources, and institutional policies supporting nurses and other providers in family care are essential to promote positive attitudes toward family engagement. A collective effort is required to change the culture and practice of family engagement by implementing evidence-based policies and guidelines. The study's findings provided significant insights that may shape and improve healthcare practice, particularly in the ICU.

Society of Critical Care Medicine Guidelines on Family-Centered Care for Adult ICUs: 2024

RATIONALE

For staff in adult ICUs, providing family-centered care is an essential skill that affects important outcomes for both patients and families. The COVID-19 pandemic placed unprecedented strain on care of ICU families, and practices for family engagement and support are still adjusting.

OBJECTIVES

To review updated evidence for family support in adult ICUs, provide clear recommendations, and spotlight optimal family-centered care practices post-pandemic.

PANEL DESIGN

The multiprofessional guideline panel of 28 individuals, including family member partners, applied the processes described in the Society of Critical Care Medicine Standard Operating Procedures Manual to develop and publish evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Conflict-of-interest policies were strictly followed in all phases of the guidelines, including panel selection, writing, and voting.

METHODS

The guidelines consist of four content sections: engagement of families, support of family needs, communication support, and support of ICU clinicians providing family-centered care. We conducted systematic reviews for 15 Population, Intervention, Control, and Outcomes questions, organized among these content sections, to identify the best available evidence. We summarized and assessed the certainty of evidence using the GRADE approach. We used the GRADE evidence-to-decision framework to formulate recommendations as strong or conditional, or as best practice statements where appropriate. The recommendations were approved using an online vote requiring greater than 80% agreement of voting panel members to pass.

RESULTS

Our panel issued 17 statements related to optimal family-centered care in adult ICUs, including one strong recommendation, 14 conditional recommendations, and two best practice statements. We reaffirmed the critical importance of liberalized family presence policies as default practice when possible and suggested options for family attendance on rounds and participation in bedside care. We suggested that ICUs provide support for families in the form of educational programs; ICU diaries; and mental health, bereavement, and spiritual support. We suggested the importance of providing structured communication for families and communication training for clinicians but did not recommend for or against any specific clinician-facing tools for family support or decision aids, based on current available evidence. We recommended that adult ICUs implement practices to systematically identify and reduce barriers to equitable critical care delivery for families and suggested that programs designed to support the wellbeing of clinicians responsible for family support be developed.

CONCLUSIONS

Our guideline panel achieved consensus regarding recommendations and best practices for family-centered care in adult ICUs.

Determining the needs of relatives of patients with a COVID-19 diagnosis in the intensive care unit

BACKGROUND

The precautions taken in the intensive care unit (ICU) during the COVID-19 pandemic have caused a change in the needs of relatives of patients.

OBJECTIVE

This research was conducted to determine the needs of relatives of ICU patients diagnosed with COVID-19.

METHODS

The sample of this cross-sectional study consisted of 68 relatives of patients treated with COVID-19 in the ICU. Data were collected with a "Patient Relatives Information Form", a "Factors Affecting the Needs of the Relatives of Patients in the Intensive Care Unit Form", and the Critical Care Family Needs Inventory (CCFNI). A multivariate and univariate general linear model was used to determine the factors affecting the CCFNI total and subscale scores. Higher CCFNI scores are indicative of higher family need.

RESULTS

The assurance (3.5 ± 0.4), information (3.4 ± 0.5), proximity (3.0 ± 0.6), comfort (2.8 ± 0.6), and support (2.7 ± 0.5) dimensions were important needs of relatives of patients hospitalised in the ICU. There was a weak negative correlation between participants' ages and CCFNI scores (p = 0.041). According to the univariate general linear model, significant difference was found between the total CCFNI scores (p = 0.032; 95% confidence interval [CI]: 2.68-3.03), based on multivariate general linear model proximity scores (p = 0.000; 95% CI: 2.49-2.91), and support scores (p = 0.029; 95% CI: 2.26-2.68) and the effect of ICU visit restrictions on relatives' anxiety. Additionally, based on the multivariate general linear model, significant difference was found between the assurance scores and the presence of people who provided support to avoid disruption of responsibilities at home (p = 0.025; 95% CI: 3.30-3.54) and between the proximity scores and the expectations of intensive care nurses (p = 0.028; 95% CI: 2.83-3.59).

CONCLUSION

This study showed that relatives of ICU patients had high levels of needs. Relatives had high needs for assurance and information, whereas their needs for comfort and support were low. As the age of patients' relatives increased, their levels of needs decreased. Relatives of the patients who received support to help with their obligations at home had increased assurance needs, and those who had anxiety about the ICU visit restrictions had increased proximity and support needs.

Perspectives of Families and Healthcare Staff on the Design of Inpatient Hospital Rooms in Saudi Arabia

Aim: This study aims to explore the relationship between the perspectives of both family members and healthcare staff regarding the design of hospital inpatient rooms. It investigates the impact of family presence on the healing environment and examines the influence of specific design elements within inpatient rooms on the extent of family presence. Background: The positive impact of family presence in healthcare settings is rooted in the notion that patients and their families are significant stakeholders in the care process. However, little is known about the influence of inpatient room design elements on family presence in healthcare settings in the Middle East. Methods: A questionnaire survey was conducted among 359 participants, encompassing patients, family visitors, and healthcare professionals from three hospitals in Saudi Arabia. The questionnaire items sought insights into the influence of design elements within inpatient rooms on family presence and the overall healing environment. Results: The results indicate a strong preference for single-patient rooms (74.5%), natural light (77.6%), comfortable seating (85.8%), and a family zone positioned by the window for unobstructed views of nature (50.5%). Furthermore, the study reveals that family presence is perceived to have positive effects on the healing environment (84.0%), patient safety (81.3%), and satisfaction with the care process (88.0%). Conclusion: This study proposes a design model for inpatient rooms that can effectively cater to the needs of patients and their families, thereby contributing to the overall improvement of healthcare building design.

Weighted gene co-expression network analysis and whole genome sequencing identify potential lung cancer biomarkers

Background

Tuberculosis (TB) leads to an increased risk of lung cancer (LC). However, the carcinogenetic mechanism of TB remains unclear. We constructed gene co-expression networks and carried out whole-exome sequencing (WES) to identify key modules, hub genes, and the most recurrently mutated genes involved in the pathogenesis of TB-associated LC.

Methods

The data used in this study were obtained from the Gene Expression Omnibus (GEO) and WES. First, we screened LC-related genes in GSE43458 and TB-related genes in GSE83456 by weighted gene co-expression network analysis (WGCNA). Subsequently, we screened differentially expressed genes related to LC and TB in GSE42834. We also performed WES of 15 patients (TB, n = 5; LC, n = 5; TB+LC, n = 5), constructed mutational profiles, and identified differences in the profiles of the three groups for further investigation.

Results

We identified 278 hub genes associated with tumorigenesis of pulmonary TB. Moreover, WES identified 112 somatic mutations in 25 genes in the 15 patients. Finally, four common genes (EGFR, HSPA2, CECR2, and LAMA3) were confirmed in a Venn diagram of the 278 hub genes and the mutated genes from WES. KEGG analysis revealed various pathway changes. The PI3K-AKT signaling pathway was the most enriched pathway, and all four genes are included in this pathway. Thus, these four genes and the PI3K-AKT signaling pathway may play important roles in LC.

Conclusion

Several potential genes and pathways related to TB-associated LC were identified, including EGFR and three target genes not found in previous studies. These genes are related to cell proliferation, colony formation, migration, and invasion, and provide a direction for future research into the mechanisms of LC co-occurring with TB. The PI3K-AKT signaling pathway was also identified as a potential key pathway involved in LC development.

The impact of visiting restrictions in intensive care units for families during the COVID-19 pandemic: An integrative review

AIM

To synthesize current evidence about the impact visiting restrictions in adult intensive care units have on family members during the COVID-19 pandemic.

DESIGN

Integrative literature review.

METHODS

A total of 104 articles were retrieved. Screening yielded a total of 23 articles which were appraised for quality. Reflexive thematic analysis was applied to synthesize findings and extract themes.

DATA SOURCES

CINAHL Plus, Ovid MEDLINE, PubMed and ProQuest databases were searched for articles between January 2020 and November 2022.

RESULTS

The findings were grouped into two main themes with six subthemes. Theme 1: not being present at the bedside, and Theme 2: altered communication added to family members' distress. Findings indicate that visiting restrictions imposed during the COVID-19 pandemic had negative consequences for family members.

CONCLUSION

The patient and their family are inherently connected, prioritizing family presence with the return of flexible, open visitation policies in ICU must be a priority to mitigate further harm and adverse outcomes for all.

REPORTING METHOD

The review complies with the PRISMA guidelines for reporting systematic reviews.

IMPLICATIONS FOR PROFESSION

Nursing leaders must be included in the development of future pandemic policies that advocate family-centred care.

NO PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was included in this review.

Family engagement in the care of infectious patients in intensive care units: A hybrid concept analysis

AIM

This study aims to define and investigate characteristics, antecedents, and consequences of the concept of family engagement in caring for patients with infectious diseases hospitalised in intensive care units.

DESIGN

This is a three-phase hybrid model study (theoretical, fieldwork, and analytical phase).

METHODS

The York University Guidelines were used in the theoretical phase, and ultimately, 16 pieces of literature related to the subject under study from 2011 to 2021 were reviewed. The content analysis was used for fieldwork phases; eight participants were interviewed. Then, the theoretical and fieldwork findings were compared, integrated, and analysed.

RESULTS

This concept has characteristics such as; awareness, belief, perception, and willingness of the nurse to engage the family; a sense of responsibility, willingness, and sacrifice of the family; the physical or virtual presence of the family; triangular interaction between the nurse, patient, and family; perception and identifying the goals; education and information transfer; team collaboration; delegation of responsibility to the family; decision making; and protection of the family. Antecedents include the availability of infrastructure; patient, family, and nurse conditions; and the quality implementation of engagement. The consequences include positive consequences related to the patient, family, nursing, and society, as well as some negative consequences. This study provided a comprehensive perception of family engagement in the care of patients with infectious diseases in intensive care units and defined it more clearly, showing its characteristics, antecedents, and consequences.

PATIENT OR PUBLIC CONTRIBUTION

Eight participants were interviewed, including five nurses, two family caregivers, and one patient.

[Effect of an Intervention Using Voice Recording of a Family Member on Patients Undergoing Mechanical Ventilator Weaning Process]

PURPOSE

This study aimed to determine the impact of an intervention using voice recording of family members on pain, anxiety, and agitation in patients undergoing weaning from mechanical ventilation.

METHODS

A randomized control pre-post experimental design was implemented to 53 participants, with 27 and 26 participants in the experimental and control groups, respectively. A 70-second voice recording of a family member, repeated three times at 10-minute intervals was used as an intervention for the experimental group. Meanwhile, participants in the control group used headset for 30 minutes. Structured instruments were utilized to measure pain, anxiety, agitation, and the weaning process. Wilcoxon Signed Ranks test and the Mann-Whitney U test, or χ² test, were used for data analysis.

RESULTS

The experimental group exhibited significant decrease in pain (Z = -3.53, p < .001), anxiety (t = 5.45, p < .001), and agitation (Z = -2.99, p = .003) scores compared with those of the control group. However, there was no significant difference between groups in the weaning process' simplification (χ² = 0.63, p = .727).

CONCLUSION

Intervention using family members' voice recording effectively reduces pain, anxiety, and agitation in patients undergoing weaning from mechanical ventilation. This can be actively utilized to provide a more comfortable process for patients.

Moral Distress and Intention to Leave During COVID: A Cross-sectional Study on the Current Nursing Workforce to Guide Nurse Leaders for the Future

OBJECTIVE

The aim of this study was to investigate how the experience of caring for COVID-19 patients, nurses' moral distress, and the current practice environment impact nurses' intention to leave.

BACKGROUND

Caring for COVID-19 patients has been associated with an increase in nurses' moral distress and an increase in nurses' turnover. To date, research has focused on nurses' moral distress, the practice environment, and intentions to leave during the pandemic's peak. The current workplace climate, including those who stayed in their positions, has not been adequately assessed.

METHODS

This cross-sectional correlational study was conducted in a Magnet® hospital.

RESULTS

Moral distress related to team/system (B = 0.64, t = 3.86, P < 0.001), nurses' participation in hospital affairs (B = -2.21, t = -3.52, P < 0.001), and staffing (B = -1.91, t = -5.48, P < 0.001) are strongest predictors for nurses' intention to leave postpandemic.

CONCLUSIONS

Nurses in practice still report experiencing COVID-related moral distress; however; issues related to resources and staffing have the most substantial impact on intention to leave among the current nursing workforce.

Post-hospital recovery trajectories of family members of critically ill COVID-19 survivors: an international qualitative investigation

PURPOSE

The immediate impact of coronavirus disease 2019 (COVID-19) visiting restrictions for family members has been well-documented. However, the longer-term trajectory, including mechanisms for support, is less well-known. To address this knowledge gap, we aimed to explore the post-hospital recovery trajectory of family members of patients hospitalised with a critical care COVID-19 admission. We also sought to understand any differences across international contexts.

METHODS

We undertook semi-structured interviews with family members of patients who had survived a COVID-19 critical care admission. Family members were recruited from Spain and the United Kingdom (UK) and telephone interviews were undertaken. Interviews were analysed using a thematic content analysis.

RESULTS

Across the international sites, 19 family members were interviewed. Four themes were identified: changing relationships and carer burden; family health and trauma; social support and networks and differences in lived experience. We found differences in the social support and networks theme across international contexts, with Spanish participants more frequently discussing religion as a form of support.

CONCLUSIONS

This international qualitative investigation has demonstrated the challenges which family members of patients hospitalised with a critical care COVID-19 admission experience following hospital discharge. Specific support mechanisms which could include peer support networks, should be implemented for family members to ensure ongoing needs are met.

Addressing clinician moral distress: Implications from a mixed methods evaluation during Covid-19

Clinician moral distress has been documented over the past several decades as occurring within numerous healthcare disciplines, often in relation to clinicians' involvement in patients' end-of-life decision-making. The resulting harms impact clinician well-being, patient well-being, and healthcare system functioning. Given Covid-19's catastrophic death toll and associated demands on end-of-life decision-making processes, the pandemic represents a particularly important context within which to understand clinician moral distress. Thus, we conducted a convergent mixed methods study to examine its prevalence, associations with clinicians' demographic and professional characteristics, and contributing circumstances among Veterans Health Administration (VA) clinicians. The study, conducted in April 2021, consisted of a cross-sectional on-line survey of VA clinicians at 20 VA Medical Centers with professional jurisdiction to place life-sustaining treatment orders working who were from a number of select specialties. The survey collected quantitative data on respondents' demographics, clinical practice characteristics, attitudes and behaviors related to goals of care conversations, intensity of moral distress during "peak-Covid," and qualitative data via an open-ended item asking for respondents to describe contributing circumstances if they had indicated any moral distress. To understand factors associated with heightened moral distress, we analyzed quantitative data using bivariate and multivariable regression analyses and qualitative data using a hybrid deductive/inductive thematic approach. Mixed methods analysis followed, whereby we compared the quantitative and qualitative datasets and integrated findings at the analytic level. Out of 3,396 eligible VA clinicians, 323 responded to the survey (9.5% adjusted response rate). Most respondents (81%) reported at least some moral distress during peak-Covid. In a multivariable logistic regression, female gender (OR 3.35; 95% CI 1.53-7.37) was associated with greater odds of moral distress, and practicing in geriatrics/palliative care (OR 0.40; 95% CI 0.18-0.87) and internal medicine/family medicine/primary care (OR 0.46; 95% CI 0.22-0.98) were associated with reduced odds of moral distress compared to medical subspecialties. From the 191 respondents who completed the open-ended item, five qualitative themes emerged as moral distress contributors: 1) patient visitation restrictions, 2) anticipatory actions, 3) clinical uncertainty related to Covid, 4) resource shortages, and 5) personal risk of contracting Covid. Mixed methods analysis found that quantitative results were consistent with these last two qualitative themes. In sum, clinician moral distress was prevalent early in the pandemic. This moral distress was associated with individual-, system-, and situation-level contributors. These identified contributors represent leverage points for future intervention to mitigate clinician moral distress and its negative outcomes during future healthcare crises and even during everyday clinical care.

Associations between delirium and SARS-CoV-2 pandemic visitor restrictions among hospitalized patients

OBJECTIVES

Delirium is associated with increased morbidity and mortality, but environmental and behavioral factors may decrease the risk of developing delirium and thus must be considered. To investigate trends in delirium prevalence and examine associations of visitor restrictions with delirium diagnoses among all patients hospitalized during and prior to the novel coronavirus SARS-CoV-2 (COVID-19) pandemic.

STUDY DESIGN

Retrospective epidemiological assessment.

METHODS

The medical records of all patients (n = 33,141) hospitalized within a three-hospital academic medical center system in a large Midwestern metropolitan area from March 20, 2019, through March 19, 2021, were analyzed.

RESULTS

The overall prevalence of delirium during COVID-19 was 11.26% (confidence interval [CI]: 10.79%, 11.73%) compared to 9.28% (CI: 8.82%, 9.73%) before COVID-19. From our adjusted logistic regression analyses, we observed that the odds of delirium among non-isolated patients were significantly higher during COVID-19 visitor restrictions (adjusted odds ratio [aOR]: 1.354; 95% CI: 1.233, 1.488; P < 0.0001) than before. The odds of delirium among isolated patients were not significantly higher during COVID-19 visitor restrictions (aOR: 1.145; 95% CI: 0.974, 1.346; P = 0.1006) than before.

CONCLUSIONS

Medically isolated patients remained at high risk of developing delirium both prior to and during COVID-19 era visitor restrictions. However, non-medically isolated patients had a significantly increased risk of delirium during the social isolation of visitor restrictions compared to prior to visitor restrictions.

Ethical Guidance on Family Caregiving, Support, and Visitation in Hospitals and Residential Health Care Facilities, Including During Public Health Emergencies: an American College of Physicians Position Paper

Public health emergencies create challenges for the accommodation of visitors to hospitals and other care facilities. To mitigate the spread of COVID-19 early in the pandemic, health care institutions implemented severe visitor restrictions, many remaining in place more than 2 years, producing serious unintended harms. Visitor restrictions have been associated with social isolation and loneliness, worse physical and mental health outcomes, impaired or delayed decision-making, and dying alone. Patients with disabilities, communication challenges, and cognitive or psychiatric impairments are particularly vulnerable without caregiver presence. This paper critically examines the justifications for, and harms imposed by, visitor restrictions during the COVID-19 pandemic and offers ethical guidance on family caregiving, support, and visitation during public health emergencies. Visitation policies must be guided by ethical principles; incorporate the best available scientific evidence; recognize the invaluable roles of caregivers and loved ones; and involve relevant stakeholders, including physicians, who have an ethical duty to advocate for patients and families during public health crises. Visitor policies should be promptly revised as new evidence emerges regarding benefits and risks in order to prevent avoidable harms.

Volunteers, religious communities and users representatives as an alternative for visiting hospitalized patients: The importance of an infection control training

BACKGROUND

During the COVID-19 pandemic, the suspension of relatives' visits was a common measure in healthcare facilities to prevent the spread of the virus among patients. This measure caused significant adverse consequences for hospitalized patients. Volunteers' intervention was an alternative but could also lead to cross transmission events.

AIMS

in order to secure their intervention with patients, we implemented an infection control training to evaluate and to improve the knowledge of volunteers about infection control measures.

METHOD

We performed a before-after study in a group of five tertiary referral teaching hospitals in the suburbs of Paris. A total of 226 volunteers from three groups (religious representatives, civilian volunteers and users' representatives) were included. Basic theoretical and practical knowledge about infection control, hand hygiene, and glove and mask use were evaluated just before and immediately after a three-hour training program. The contribution of the characteristics of the volunteers to the results was studied.

FINDINGS

The initial conformity rate for theoretical and practical infection control measures ranged from 53% to 68%, depending on the participants' activity status and education level. Some critical shortcomings in hand hygiene as well as mask and glove wearing putatively endangered the patients and volunteers. Surprisingly, serious gaps were also identified among volunteers who experienced care activities. Regardless of their origin, the program significantly improved both their theoretical and practical knowledge (p<0.001). Real-life observance and long-term sustainability should be monitored.

CONCLUSIONS

To become a secure alternative to relatives' visits, volunteers' interventions must be preceded by the assessment of their theoretical knowledge and practical skills in infection control. Additional study, including practice audit, must confirm the implementation of the acquired knowledge in the real-life.

A Concept Analysis of Family Presence During COVID-19

BACKGROUND

In 2020, the COVID-19 pandemic required health care organizations throughout the United States to implement strict visitor restriction policies to mitigate the spread of the virus. These policy changes had a direct impact on family presence (FP) in hospital settings.

PURPOSE

The aim of this study was to conduct a concept analysis of FP during the COVID-19 pandemic.

METHODS

Walker and Avant's 8-step method was used.

RESULTS

Four defining attributes of FP during COVID-19 were derived based on a review of the literature: being there or with, seeing is believing, during challenging times, and subjective advocates. The COVID-19 pandemic was the main antecedent of the concept. The consequences and empirical referents were discussed. Model, borderline, and contrary cases were developed.

CONCLUSION

This concept analysis provided an understanding of the concept of FP during COVID-19, which is imperative to optimizing patient care outcomes, as literature identified a support person or system as an extension of the care team that facilitates successful care management. Whether by advocating for their patients to have a support person present during team rounds, or by stepping in as the patient's main support system in the absence of family, nurses must find a way to do what is best for their patients even during the unprecedented times of a global pandemic.

Daily Oxygenation Support for Patients Hospitalized With SARS-CoV-2 in an Integrated Health System

BACKGROUND

Many COVID-19 studies are constructed to report hospitalization outcomes, with few large multi-center population-based reports on the time course of intra-hospitalization characteristics, including daily oxygenation support requirements. Comprehensive epidemiologic profiles of oxygenation methods used by day and by week during hospitalization across all severities are important to illustrate the clinical and economic burden of COVID-19 hospitalizations.

METHODS

This was a retrospective, multi-center observational cohort study of 15,361 consecutive hospitalizations of patients with COVID-19 at 25 adult acute care hospitals in Texas participating in the Society of Critical Care Medicine Discovery Viral Respiratory Illness Universal Study COVID-19 registry.

RESULTS

At initial hospitalization, the majority required nasal cannula (44.0%), with an increasing proportion of invasive mechanical ventilation in the first week and particularly the weeks to follow. After 4 weeks of acute illness, 69.9% of adults hospitalized with COVID-19 required intermediate (eg, high-flow nasal cannula, noninvasive ventilation) or advanced respiratory support (ie, invasive mechanical ventilation), with similar proportions that extended to hospitalizations that lasted ≥ 6 weeks.

CONCLUSIONS

Data representation of intra-hospital processes of care drawn from hospitals with varied size, teaching and trauma designations is important to presenting a balanced perspective of care delivery mechanisms employed, such as daily oxygen method utilization.

Exploring family caregiver challenges in caring for patients with COVID-19 in intensive care units

Background

Families of individuals hospitalized in an intensive care unit (ICU) with severe illnesses, such as COVID-19, are experiencing a range of physical and emotional stressors. Identifying the challenges faced by family members and providing support to loved ones battling life-threatening diseases can lead to improved treatment and care for the said family members in a healthcare setting.

Aim

The current study was conducted to explore and understand the experiences of family caregivers caring for their loved ones battling COVID-19 in an ICU.

Methods

This descriptive qualitative study was conducted from January 2021 to February 2022, based on the experiences of 12 family caregivers of patients with COVID-19 hospitalized in the ICU. Data collection was conducted through purposeful sampling using semi-structured interviews. MAXQDA10 software was used for data management, and conventional content analysis was used for qualitative data analysis.

Results

The present study conducted interviews with caregivers to understand their experiences while caring for a loved one in an ICU. Three main themes emerged from the analysis of these interviews: hardship of care trajectory, pre-loss mourning, and contributing factors in resolving family health crises. The first theme, the hardship of care trajectories, encompasses categories such as immersion in the unknown, lack of care facilities, negligence in care, neglect of families by healthcare providers, self-ignorance, and perceived stigma. The second these was pre-loss mourning that included some categories such as emotional and psychological turmoil, witnessing the exhaustion of loved ones, separation suffering, the fearing of loss, anticipatory grief, blame related to the disease causative agents, and perceived helplessness and despair. The third theme was contributing factors in resolving family health crises that included categories of the critical role of family caregivers in health engagement, the role of healthcare professionals in health engagement, and the role of interpersonal factors in health engagement. A total of 80 subcategories were also obtained based on the experiences of the family caregivers.

Conclusion

This study's findings indicate that families can play an important role in resolving their loved ones' health problems in life-threatening situations such as the COVID-19 pandemic. Moreover, healthcare providers must recognize and prioritize family-based care and trust the families' ability to effectively manage health crises. Healthcare providers should also be attentive to the needs of both the patient and their family members.

Family support in intensive care units during COVID-19 visit ban: A multinational Delphi Study during first COVID-19 wave

OBJECTIVES

This study assessed opinions and experiences of healthcare professionals, former patients and family members during the first wave of the COVID-19 pandemic and focuses on challenges in family-centred care for intensive care unit patients and affected families.

RESEARCH METHODOLOGY/DESIGN

A two-round modified Delphi process assessed the opinions and experiences of experts such as healthcare professionals, former patients and their families (n = 151).

SETTING

This study was conducted across four countries in Europe.

RESULTS

In total, 121 participants (response rate 80.13%) answered the first Delphi round; the second was answered by 131 participants (response rate 86.75%). Participants perceived family support in the intensive care unit as highly important during the COVID-19 pandemic. Enabling contact amongst patients, families and clinicians is regarded as essential to build hope and confidence in the treatment and the recovery process. The extraordinary situation led to the implementation of new communication structures such as video calls and websites.

CONCLUSION

A consensus was reached between healthcare professionals that virtual contact is essential for patients with COVID-19 and their families during visit restrictions. This should be done to establish confidence in the treatment.

Incidence and Risk of Lung Cancer in Tuberculosis Patients, and Vice Versa: A Literature Review of the Last Decade

Background

The incidence and risk of both lung cancer (LC) and tuberculosis (TB) are increasing rapidly. These two diseases frequently exist together and can influence the incidence and risk of each other. The aim of the current review was to summarize the incidence and risk of LC in TB patients, and vice versa, short out research gap, and contemplate future research perspectives. Methodology. PubMed and Scopus databases, and Google Scholar search engine were searched for epidemiological studies that investigated the incidence and risk of TB and LC, published since January 2011 to April 2022, and written in English. We used the searching keyword "tuberculosis" combined with "lung cancer" and associated medical subject heading (MeSH) to retrieve eligible research articles. We retrieved information's regarding the diagnosis of TB and LC, confounders, the associations of TB and LC, and incidence and risks of each other.

Results

We found higher incidence rate and risks (1.64 to 6 times higher) of LC in TB patients in comparison to non-TB participants. However, the incidence rate and risks of TB in LC patients were comparatively low. Male patients were exhibited higher risks than female. The medical comorbidities, smoking habits, and age can also influence the associations and risks of LC in TB patients or vice versa.

Conclusion

Our summarized studies might suggest that existing active TB may increase the incidence and risk of LC. However, large prospective cohort study is warranted to explore the real scenario worldwide.

Frailty and emergency surgery: identification and evidence-based care for vulnerable older adults

Frailty is a multidimensional state related to accumulation of age- and disease-related deficits across multiple domains. Older people represent the fastest growing segment of the peri-operative population, and 25-50% of older surgical patients live with frailty. When frailty is present before surgery, adjusted rates of morbidity and mortality increase at least two-fold; the odds of delirium and loss of independence are increased more than four- and five-fold, respectively. Care of the older person with frailty presenting for emergency surgery requires individualised and evidence-based care given the high-risk and complex nature of their presentations. Before surgery, frailty should be assessed using a multidimensional frailty instrument (most likely the Clinical Frailty Scale), and all members of the peri-operative team should be aware of each patient's frailty status. When frailty is present, pre-operative care should focus on documenting and communicating individualised risk, considering advanced care directives and engaging shared decision-making when feasible. Shared multidisciplinary care should be initiated. Peri-operatively, analgesia that avoids polypharmacy should be provided, along with delirium prevention strategies and consideration of postoperative care in a monitored environment. After the acute surgical episode, transition out of hospital requires that adequate support be in place, along with clear discharge instructions, and review of new and existing prescription medications. Advanced care directives should be reviewed or initiated in case of readmission. Overall, substantial knowledge gaps about the optimal peri-operative care of older people with frailty must be addressed through robust, patient-oriented research.

Family presence during patient acute deterioration: A survey of nurses' attitudes and reflection on COVID-19 in an African setting

Introduction

Acute deterioration refers to a patient who has become physiologically unstable requiring acute care. Family presence during resuscitation efforts has been widely supported by literature. Nurses are often the primary contact for the families of patients in the emergency centre, playing an important role in facilitating family presence during acute care. To describe nurses' attitudes regarding family presence during the management of acutely deteriorating patients in the emergency centre.

Methods

A descriptive quantitative study was conducted in the emergency centres of three public hospitals in the Eastern Cape, South Africa. A total sample of professional nurses (n = 57) were recruited, to complete the Emergency Department Family Presence (EDFP) survey. Statements about the negative effects of family presence during acute care of a deteriorating patient were presented and respondents were required to agree or disagree. Data were analysed using univariable and multivariable logistic regression.

Results

The majority of the nurses agreed with the items in the EDFP survey agreeing that present relatives may misinterpret activities of health care professionals (92.8%) which can result in complaints about the quality of care (91.1%). Nurses with more years of experience (11-21 years) were more likely to disagree with the statements on family presence having negative effects on patient care than nurses with fewer years of experience (0-10 years) (OR:6.92; 95%CI: 1.29-37.28).

Discussion

Nurses have the perception that family presence has a largely negative effect on patients, patient care and the families present during acute care. The contextual application of the practice of family presence during acute deterioration in an African setting needs investigation and the need for continued professional education on family centred care is emphasised. Alternative methods of facilitating family presence during the COVID-19 Pandemic must be considered as we advocate for the self determination of families and patients.

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.

Interviews with primary care physicians identify unmet transition needs after ICU

AIM

We sought to explore unmet needs in transitions of care for critical illness survivors that concern primary care physicians.

FINDINGS

Semi-structured interviews with primary care physicians identified three categories of concerns about unmet transition needs after patients' ICU stays: patients' understanding of their ICU stay and potential complications, treatments or support needs not covered by insurance, and starting and maintaining needed rehabilitation and assistance across transitions of care.

CONCLUSION

Given current constraints of access to coordinated post-ICU care, efforts to identify and address the post-hospitalization needs of critical illness survivors may be improved through coordinated work across the health system.

A Global Survey on Diagnostic, Therapeutic and Preventive Strategies in Intensive Care Unit-Acquired Weakness

Background and Objectives: Intensive care unit-acquired weakness (ICU-AW) is one of the most frequent neuromuscular complications in critically ill patients. We conducted a global survey to evaluate the current practices of diagnostics, treatment and prevention in patients with ICU-AW. Materials and Methods: A pre-survey was created with international experts. After revision, the final survey was endorsed by the European Society of Intensive Care Medicine (ESICM) using the online platform SurveyMonkey®. In 27 items, we addressed strategies of diagnostics, therapy and prevention. An invitation link was sent by email to all ESICM members. Furthermore, the survey was available on the ESICM homepage. Results: A total of 154 healthcare professionals from 39 countries participated in the survey. An ICU-AW screening protocol was used by 20% (28/140) of participants. Forty-four percent (62/141) of all participants reported performing routine screening for ICU-AW, using clinical examination as the method of choice (124/141, 87.9%). Almost 63% (84/134) of the participants reported using current treatment strategies for patients with ICU-AW. The use of treatment and prevention strategies differed between intensivists and non-intensivists regarding the reduction in sedatives (80.0% vs. 52.6%, p = 0.002), neuromuscular blocking agents (76.4% vs. 50%, p = 0.004), corticosteroids (69.1% vs. 37.2%, p < 0.001) and glycemic control regimes (50.9% vs. 23.1%, p = 0.002). Mobilization and physical activity are the most frequently reported treatment strategies for ICU-AW (111/134, 82.9%). The availability of physiotherapists (92/134, 68.7%) and the lack of knowledge about ICU-AW within the medical team (83/134, 61.9%) were the main obstacles to the implementation of the strategies. The necessity to develop guidelines for the screening, diagnosing, treatment and prevention of ICU-AW was recognized by 95% (127/133) of participants. Conclusions: A great heterogeneity regarding diagnostics, treatment and prevention of ICU-AW was reported internationally. Comprehensive guidelines with evidence-based recommendations for ICU-AW management are needed.

Maintaining person-centred care in hospitals during restrictions on family presence

Providing person-centred care to hospitalised patients and their families can be challenging in the context of restrictions on visiting, such as those widely implemented in healthcare settings during the coronavirus disease 2019 (COVID-19) pandemic. In the US, several strategies have been deployed to work around the restrictions on family presence in hospitals, most of which focused on communication between the patient and family, and collaboration between the family and the healthcare team. Sharp Memorial Hospital, an acute care hospital in San Diego California, US, was determined to maintain its person-centred care practices during the pandemic. A Family Resource Centre started operating in March 2020 with the aim of enabling hospitalised patients and their families to connect in a safe manner. This article describes this innovative approach to maintaining person-centred care in hospital during restrictions on family presence.

Determination of patients’ family members’ needs and related factors in the intensive care unit with visiting restrictions during the COVID-19 pandemic

Objectives

To determine the needs of family members of patients and related factors in the intensive care unit during the COVID-19 pandemic.

Research methodology

This descriptive, cross-sectional, and correlational type study was conducted with a total of 301 family members. Data were collected by using two validated inquiry forms, the “Introductory Information Form” and the “Critical Care Family Needs Inventory” through an online survey. Descriptive statistical methods, as well as the Mann-Whitney U test, Kruskal-Wallis test, Dunn-Bonferroni test, and Backward Linear Regression Analysis, were used for the analysis of data.

Results

The average scores of information, assurance, proximity, support, and comfort needs of family members were 3.54 ± 0.61 (Min = 1.11-Max = 4), 3.72 ± 0.60 (Min = 1-Max = 4), 3.50 ± 0.62 (Min = 1-Max = 4), 3.27 ± 0.77 (Min = 1.07-Max = 4), and 3.32 ± 0.73 (Min = 1-Max = 4), respectively. A very weak positive correlation was found between the ages of family members and information, assurance, and proximity needs (p < 0.05). Some variables such as sex, income level, and degree of affinity had significant effects on the needs of family members (p < 0.05).

Conclusion

Family members of critically ill patients had needs at most in the assurance sub-dimension during the COVID-19 pandemic. As the length of time of family members spent in the hospital increased, their support and comfort sub-dimension needs also increased. Institutional policies should be developed to assure family members in intensive care units.

COVID-19 pandemic: the impact on Canada’s intensive care units

The COVID-19 pandemic has exposed the precarious demand-capacity balance in Canadian hospitals, including critical care where there is an urgent need for trained health care professionals to dramatically increase ICU capacity.

The impact of the pandemic on ICUs varied significantly across the country with provinces that implemented public health measures later and relaxed them sooner being impacted more severely. Pediatric ICUs routinely admitted adult patients. Non-ICU areas were converted to ICUs and staff were redeployed from other essential service areas. Faced with a lack of critical care capacity, triage plans for ICU admission were developed and nearly implemented in some provinces.

Twenty eight percent of patients in Canadian ICUs who required mechanical ventilation died. Surviving patients have required prolonged ICU admission, hospitalization and extensive ongoing rehabilitation. Family members of patients were not permitted to visit, resulting in additional psychological stresses to patients, families, and healthcare teams. ICU professionals also experienced extreme psychological stresses from caring for such large numbers of critically ill patients, often in sub-standard conditions. This resulted in large numbers of health workers leaving their professions.

This pandemic is not yet over, and it is likely that new pandemics will follow. A review and recommendations for the future are provided.

"Compassion Cannot Choose:" A Call for Family-centered Critical Care during the COVID-19 Pandemic

Compassion has been one of the greatest virtues of healthcare professionals. In the early phase of the pandemic, a lot of caution was essential, and restrictions were imposed on the hospital visitation of the COVID-19 patients by their family members. The healthcare system was overburdened, and the healthcare workers were apprehensive about the new virus and the rising mortality. Compassion and family-centered care took a step back as survival of the pandemic became the ultimate goal of mankind. ”COVID-19 patients admitted to the critical care units, their loved ones and the healthcare professionals caring for these patients took the brunt of the emotional and psychological impacts of the pandemic.” However, as we have moved more than a year into the pandemic, knowledge and resources we gained may be leveraged to provide family-centered critical care for COVID-19 patients. Family presence in intensive care units (ICUs) has been associated with higher satisfaction with care, collaboration with the medical team, shared decision-making, reduced delirium, and optimized end-of-life care of COVID-19 patients. The policymakers should review the restrictions, consider a holistic approach, and take appropriate actions to provide safe family-centered critical care for COVID-19 patients.

Content and Communication of Inpatient Family Visitation Policies During the COVID-19 Pandemic: Sequential Mixed Methods Study

BACKGROUND

Inpatient health care facilities restricted inpatient visitation due to the COVID-19 pandemic. There is no existing evidence of how they communicated these policies to the public nor the impact of their communication choices on public perception.

OBJECTIVE

This study aims to describe patterns of inpatient visitation policies during the initial peak of the COVID-19 pandemic in the United States and the communication of these policies to the general public, as well as to identify communication strategies that maximize positive impressions of the facility despite visitation restrictions.

METHODS

We conducted a sequential, exploratory, mixed methods study including a qualitative analysis of COVID-19 era visitation policies published on Pennsylvania-based facility websites, as captured between April 30 and May 20, 2020 (ie, during the first peak of the COVID-19 pandemic in the United States). We also conducted a factorial survey-based experiment to test how key elements of hospitals' visitation policy communication are associated with individuals' willingness to seek care in October 2020. For analysis of the policies, we included all inpatient facilities in Pennsylvania. For the factorial experiment, US adults were drawn from internet research panels. The factorial survey-based experiment presented composite policies that varied in their justification for restricted visitation, the degree to which the facility expressed ownership of the policy, and the inclusion of family-centered care support plans. Our primary outcome was participants' willingness to recommend the hypothetical facility using a 5-point Likert scale.

RESULTS

We identified 104 unique policies on inpatient visitation from 363 facilities' websites. The mean Flesch-Kincaid Grade Level for the policies was 14.2. Most policies prohibited family presence (99/104, 95.2%). Facilities justified the restricted visitation policies on the basis of community protection (59/104, 56.7%), authorities' guidance or regulations (34/104, 32.7%), or scientific rationale (23/104, 22.1%). A minority (38/104, 36.5%) addressed how restrictive visitation may impair family-centered care. Most of the policies analyzed used passive voice to communicate restrictions. A total of 1321 participants completed the web-based survey. Visitation policy elements significantly associated with willingness to recommend the facility included justifications based on community protection (OR 1.44, 95% CI 1.24-1.68) or scientific rationale (OR 1.30, 95% CI 1.12-1.51), rather than those based on a governing authority. The facility expressed a high degree of ownership over the decision (OR 1.16, 95% CI 1.04-1.29), rather than a low degree of ownership; and inclusion of family-centered care support plans (OR 2.80, 95% CI 2.51-3.12), rather than no such support.

CONCLUSIONS

Health systems can immediately improve public receptiveness of restrictive visitation policies by emphasizing community protection, ownership over the facility's policy, and promoting family-centered care.

Voices From the Pandemic: A Qualitative Study of Family Experiences and Suggestions Regarding the Care of Critically Ill Patients

Rationale

Intensive care unit (ICU) visitation restrictions during the coronavirus disease (COVID-19) pandemic have drastically reduced family-engaged care. Understanding the impact of physical distancing on family members of ICU patients is needed to inform future policies.

Objectives

To understand the experiences of family members of critically ill patients with COVID-19 when physically distanced from their loved ones and to explore ways clinicians may support them.

Methods

This qualitative study of an observational cohort study reports data from 74 family members of ICU patients with COVID-19 at 10 United States hospitals in four states, chosen based on geographic and demographic diversity. Adult family members of patients admitted to the ICU with COVID-19 during the early phase of the pandemic (February–June 2020) were invited to participate in a phone interview. Interviews followed a semistructured guide to assess four constructs: illness narrative, stress experiences, communication experiences, and satisfaction with care. Interviews were transcribed verbatim and analyzed using an inductive approach to thematic analysis.

Results

Among 74 interviewees, the mean age was 53.0 years, 55% were white, and 76% were female. Physical distancing contributed to substantial stress and harms (nine themes). Participants described profound suffering and psychological illness, unfavorable perceptions of care, and weakened therapeutic relationship between family members and clinicians. Three communication principles emerged as those most valued by family members: contact, consistency, and compassion (the 3Cs). Family members offered suggestions to guide clinicians faced with communicating with physically distanced families.

Conclusions

Visitation restrictions impose substantial psychological harms upon family members of critically ill patients. Derived from the voics of family members, our findings warrant strong consideration when implementing visitation restrictions in the ICU and advocate for investment in infrastructure (including staffing and videoconferencing) to support communication. This study offers family-derived recommendations to operationalize the 3Cs to guide and improve communication in times of physical distancing during the COVID-19 pandemic and beyond.