Developing an Innovative System of Open and Flexible, Patient-Family-Centered, Virtual Visiting in ICU During the COVID-19 Pandemic: A Collaboration of Staff, Patients, Families, and Technology Companies

Emergency Nursing and Staff Experiences With Visitation Restrictions During the Coronavirus Disease 2019 Pandemic: A Qualitative Descriptive Study

INTRODUCTION

At the onset of the coronavirus disease 2019 pandemic, visitors were prohibited in the emergency department, leaving patients bereft of their companionship and advocacy. However, little was known about the conflicts and distress of emergency department staff related to this policy. This study aimed to qualitatively explore emergency nursing and staff experiences regarding the no-visitor policy.

METHODS

A qualitative descriptive approach explored short answers to 1 open-ended question. Emergency nurses and assistive personnel (patient care technicians and emergency medical technicians/paramedics) were recruited from 11 participating emergency departments, using convenience sampling and a web-based survey. We followed the 6-step process of reflexive thematic analysis to identify patterns in the data and develop themes that describe the results.

RESULTS

Of 180 respondents, 69 (38%) answered our qualitative question. Participants were typically female (78.3%), White (82.6%), and mostly registered nurses (79.7%), with an average age of 39 years and an average of 10 years' ED experience. Participants offered complex, heartfelt responses, resulting in 3 themes: (1) exposure and risk, (2) experiencing patient and family reactions; and (3) policy enforcement challenges.

DISCUSSION

Although many respondents concluded that the policy was protective against pandemic risk, some saw it as ineffective. They believed exceptions must be made for imminent death. Participants felt that patients/visitors understood, but did not always like, restrictions. Adherence to policy left respondents conflicted, leading to inconsistent enforcement. Visitation policies for patients with infectious diseases must consider patient/visitor needs, moral distress of ED staff, and pragmatic enforcement strategies.

Ethical considerations related to virtual visiting for families and critically ill patients in intensive care: a qualitative descriptive study

BACKGROUND

During the COVID-19 pandemic, virtual visiting technologies were rapidly integrated into the care offered by intensive care units (ICUs) in the UK and across the globe. Today, these technologies offer a necessary adjunct to in-person visits for those with ICU access limited by geography, work/caregiving commitments, or frailty. However, few empirical studies explore the ethical issues associated with virtual visiting. This study aimed to explore the anticipated or unanticipated ethical issues raised by using virtual visiting in the ICU, such that healthcare professionals can be informed about how to carry out virtual visits ethically, safely and productively.

METHODS

We used a descriptive exploratory qualitative research approach recruiting a convenience sample of newly-graduated junior doctors facilitating ICU virtual visits in a tertiary academic centre. Eight newly graduated junior doctors, seven female and one male, aged 23-27, participated in semi-structured interviews. We analysed transcripts using an inductive coding approach.

RESULTS

Five overarching themes emerged. Two of the themes namely, 'fulfilling a moral instinct to connect families' and 'promoting autonomy', arose from participants' descriptions of how virtual visits aligned with healthcare standards and practices they considered ethical. Three further themes, 'preserving dignity and privacy', 'managing emotional distress', and 'providing equitable access' to virtual visiting technologies, highlight how virtual visits might exacerbate ethical issues related to family communications.

CONCLUSION

Virtual visiting may potentially both ameliorate and exacerbate aspects of ethical healthcare delivery for ICU patients and family members. ICU team members should consider unique ethical considerations related to using virtual visiting. We recommend virtual communications skills training for staff and advocate for the use of easily accessible educational resources for families who wish to visit critically unwell patients remotely.

Hospital visiting hours - do they need to be revised?

Objective This study aimed to determine the number of visitors to an acute hospital, the time of visit, destination, and details of parking over the same period. Methods A prospective observational pilot study in a large metropolitan public hospital in Australia was performed. The research team observed all visitors over a 14-day period between 17 and 30 October 2022 counting the people visiting relatives or friends of admitted hospital patients as well as those visiting outpatient clinics during the observation period. Other outcome measures included time of the visit, destination, and estimated costs of parking. Results During the 14 days of observation there were 18,066 visitors, averaging 1290 per day. The majority were visitors to inpatients (62.2%, 11,232, averaging 802 per day). Those attending outpatients were less (37.8%, 6834, averaging 668 per weekday). The estimated average parking cost was A$18.10 per day normally and A$11.85 for concessions. Conclusions This was the first known study on hospital-wide visiting in Australia or globally. These findings would be important for addressing issues such as hospital planning, and for future research including the impact of visiting on patient outcomes, the patient and community experience, and the expectations and experience of hospital visitors.

Experiences of healthcare professionals, patients and families with video calls to stimulate patient- and family-centred care during hospitalization: A scoping review

AIM

To synthesize the literature on the experiences of patients, families and healthcare professionals with video calls during hospital admission. Second, to investigate facilitators and barriers of implementation of video calls in hospital wards.

DESIGN

Scoping review.

METHODS

PubMed, CINAHL and Google Scholar were searched for relevant publications in the period between 2011 and 2023. Publications were selected if they focused on experiences of patients, families or healthcare professionals with video calls between patients and their families; or between families of hospitalized patients and healthcare professionals. Quantitative and qualitative data were summarized in data charting forms.

RESULTS

Forty-three studies were included. Patients and families were satisfied with video calls as it facilitated daily communication. Family members felt more engaged and felt they could provide support to their loved ones during admission. Healthcare professionals experienced video calls as an effective way to communicate when in-person visits were not allowed. However, they felt that video calls were emotionally difficult as it was hard to provide support at distance and to use communication skills effectively. Assigning local champions and training of healthcare professionals were identified as facilitators for implementation. Technical issues and increased workload were mentioned as main barriers.

CONCLUSION

Patients, families and healthcare professionals consider video calls as a good alternative when in-person visits are not allowed. Healthcare professionals experience more hesitation towards video calls during admission, as it increases perceived workload. In addition, they are uncertain whether video calls are as effective as in-person conservations.

IMPLICATIONS FOR THE CLINICAL PRACTICE

When implementing video calls in hospital wards, policymakers and healthcare professionals should select strategies that address the positive aspects of family involvement at distance and the use of digital communication skills.

PATIENT CONTRIBUTION

No patient or public contribution.

Family-centered delirium prevention and treatment using video calls: the FACE Delirium trial

PURPOSE

In the FACE Delirium trial, we investigated the feasibility of a structured FAmily-CEntered delirium prevention and treatment during the corona pandemic.

METHODS

Patients hospitalized in a German geriatric medicine department were included in this single-center, prospective, single-arm feasibility study. Their relatives received a short training on delirium and volunteers or paid staff members facilitated video calls. The primary endpoint was reached when contact between patients and their relatives occurred on ≥ 80% of treatment days, either via video call or visit.

RESULTS

38 patients were included (age 83.0 ± 5.9 years; 73.7% women). 76.3% reached the primary endpoint. Due to the pandemic, 99.3% of the contacts were video calls with a duration of 24.8 ± 16.3 min.

CONCLUSION

Family-centered delirium prevention and treatment using video calls is feasible among hospitalized geriatric patients. Daily implementation in clinical practice poses challenges and requires motivated and qualified staff.

Nonface-to-Face Visitation to Restrict Patient Visits for Infection Control: Integrative Review

BACKGROUND

In the COVID-19 pandemic, a visit restriction policy for patients has been implemented in medical institutions worldwide and visits are being made using alternative communication technologies. This shift has also required the use of platforms to prevent negative consequences of these restrictions.

OBJECTIVE

The purpose of this review was to comprehensively explore nonface-to-face visits as an alternative during infection prevention and to synthesize the scientific evidence of their benefits and disadvantages.

METHODS

A comprehensive search was conducted via the PubMed, Embase, CINAHL, Cochrane, and Web of Science electronic databases; unpublished trials in the clinical trials register ClinicalTrials.gov; and Virginia Henderson International Nursing Library up to September 10, 2021. The search query was developed according to the guidelines of the Peer Review of Electronic Search Strategies and included keywords on the topics of telemedicine and visitation restrictions. The inclusion criteria were a nonface-to-face modality using telemedicine with family in a hospital setting, experimental and observational studies, and articles written in English. The exclusion criteria were inaccessible in full text, not related to patient or family involvement, mainly focused on the study protocol, or only discussing the pros and cons of telemedicine.

RESULTS

Overall, patients' families experienced emotional distress due to restrictions on face-to-face visits. Nonface-to-face virtual visits compensating for these restrictions had a positive effect on reducing the risk of infection to the patient and the family. This further encouraged psychological and physical recovery and decreased psychological distress. However, nonface-to-face virtual technology could not replace the existence of actual families, and technical problems with networks and devices are reported as limitations.

CONCLUSIONS

Ensuring the availability of technology and educating on the same in alignment with the characteristics of patients and their families, nonface-to-face virtual visits need to show more potential as an effective patient-centered treatment strategy based on more research and advanced practice.

Strategies Used by Nurses to Maintain Person-Family Communication during the COVID-19 Pandemic: A Scoping Review

Background: The COVID-19 pandemic made nurse-patient-family communication more difficult, reducing the understanding of the patient's wishes and current care history. COVID-19 challenged healthcare teams to develop strategies to address these changes and provide more integrated care using the technology at their disposal. So, this study aims to map the strategies used by nurses to maintain communication between the person hospitalized with COVID-19 and the family to understand which communication technologies were most used to maintain communication between the person and the family. Methods: A Scoping Review, according to the recommendations of the Joanna Briggs Institute [JBI] with the Preferred Reporting Items for Scoping Review extension (PRISMA-ScR), research conducted between September 2022 and January 2023. The search was conducted in the databases: Latin American and Caribbean Literature in Health Sciences (LILACS); Cumulative Index of Nursing and Allied Health Literature (CINAHL); Scientific Electronic Library Online (SciELO); Medical Literature Analysis and Retrieval System Online (Medline), using the descriptors: family, communication, nurses, hospitals and COVID-19, and the Boolean operators "AND". The inclusion criteria were: original articles, in Portuguese, English, and Spanish, published from 2020 onwards, with access to full and free text. Results: It was found that most of the communication was unstructured with the family. The technologies most used by nurses were the telephone with video calls from the patients themselves and even from health professionals to maintain communication between the patient and the family. Conclusions: Communication between patients and families became essential during the pandemic, as it became a vital lifeline of human connection that supported the mental health of patients and their families. This study was not registered.

Improving Neurology Inpatient Fall Rate: Effect of a Collaborative Interdisciplinary Quality Improvement Initiative

Objective

To reduce unwitnessed inpatient falls on the neurology services floor at an academic medical center by 20% over 15 months.

Patients and Methods

A 9-item preintervention survey was administered to neurology nurses, resident physicians, and support staff. Based on survey data, interventions targeting fall prevention were implemented. Providers were educated during monthly in-person training sessions regarding the use of patient bed/chair alarms. Safety checklists were posted inside each patient's room reminding staff to ensure that bed/chair alarms were on, call lights and personal items were within reach, and patients' restroom needs were addressed. Preimplementation (January 1, 2020, to March 31, 2021) and postimplementation (April 1, 2021, to June 31, 2022) rates of falls in the neurology inpatient unit were recorded. Adult patients hospitalized in 4 other medical inpatient units not receiving the intervention served as a control group.

Results

Rates of falls, unwitnessed falls, and falls with injury all decreased after intervention in the neurology unit, with rates of unwitnessed falls decreasing by 44% (2.74 unwitnessed falls per 1000 patient-days before intervention to 1.53 unwitnessed falls per 1000 patient-days after intervention; P=.04). Preintervention survey data revealed a need for education and reminders on inpatient fall prevention best practices given a lack of knowledge on how to operate fall prevention devices, driving the implemented intervention. All staff reported significant improvement in operating patient bed/chair alarms after intervention (P<.001).

Conclusion

A collaborative, multidisciplinary approach focusing on provider fall prevention education and staff checklists is a potential technique to reduce neurology inpatient fall rates.

Family experiences and perceptions of intensive care unit care and communication during the COVID-19 pandemic

INTRODUCTION

In 2020, during the first wave of the COVID-19 pandemic in Melbourne, visitor access to acute hospitals including intensive care units (ICUs) was initially barred, followed by a limit of one person per patient for one hour per day. This study explores the care and communication experienced by family members of ICU patients during this time.

METHODS

This qualitative descriptive study was conducted at an Australian quaternary hospital. Semistructured phone interviews were conducted using an aide-memoire designed to understand participants' experiences as family of a patient during this time. Interviews were recorded, transcribed, and thematically analysed.

FINDINGS

Twenty family members of patients in the ICU participated. Three major themes were identified: 'impact of restricting visiting procedures', 'family experiences of communication', and 'care and support'. Inflexible visiting restrictions had a momentous impact on families. Participants objected to having to nominate only two people to visit during the admission and the short visiting time limit. Some family members suffered extreme stress and anxiety during their absence from the bedside. Additional challenges were experienced by rural families, visitors with disabilities, and the young children of patients who were excluded. Communication with clinicians varied. Telehealth was valued by some but not universally embraced. The relationship between staff members and families and involvement in decision-making were unaffected.

CONCLUSION

Families experienced significant psychological distress from being separated from their critically ill relatives. Patient care and involvement in decision-making appeared to be unchanged, but communication with staff felt to be lacking. Better alternatives to face-to-face communication must be sought to limit the impact of family separation on mental health. Families are a key link between the patient and clinicians and often play a major role in patient support and recovery after discharge. There is an urgent need to support them and facilitate meaningful engagement despite the obstacles.

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.

"I don't know how we would have coped without it." Understanding the Importance of a Virtual Hospital Visiting Program During the COVID-19 Pandemic

As the COVID-19 pandemic reached Canada in full strength, the concept of allowing visiting to patients became an impossibility in most healthcare organizations. In March 2020, hospitals across Canada made the decision to close to visitors. This was a complicated decision which left admitted patients with very little option for connecting with family and friends other than through the telephone. In response, North York General Hospital launched a virtual family visiting (VFV) program across all inpatient units. Here we report the findings of a qualitative study of the program informed by an interpretive descriptive approach. Interviews were conducted with families who participated in the VFV program at North York General Hospital in Toronto, Canada during the first wave of the COVID pandemic. A total of 24 family members were interviewed. As anticipated, the family members were all extremely pleased with the opportunity to connect virtually and very satisfied with the VFV program. What was less anticipated was the anxiety and distress that families experienced in being separated from their loved ones. Our data analysis revealed 4 key themes which we have labeled (a) the unforeseen consequences of separation trauma, (b) increased vulnerability of patients and family, (c) a lifeline of human connection, and (d) the role of the facilitator as a connector. This work contributes significantly to a system-level understanding of the impact of imposed separation, increased vulnerability, and the importance of providing an alternative way for families to be present with their loved ones in these unprecedented times.

Family satisfaction with intensive care unit communication during the COVID-19 pandemic: a prospective multicentre Australian study Family Satisfaction - COVID ICU

BACKGROUND

Virtual communication has become common practice during the coronavirus disease 2019 (COVID-19) pandemic because of visitation restrictions.

AIMS

The authors aimed to evaluate overall family satisfaction with the intensive care unit (FS-ICU) care involving virtual communication strategies during the COVID-19 pandemic period.

METHODS

In this prospective multicentre study involving three metropolitan hospitals in Melbourne, Australia, the next of kin (NOK) of all eligible ICU patients between 1 July 2020 and 31 October 2020 were requested to complete an adapted version of the FS-ICU 24-questionnaire. Group comparisons were analysed and calculated for family satisfaction scores: ICU/care (satisfaction with care), FS-ICU/dm (satisfaction with information/decision-making) and FS-ICU/total (overall satisfaction with the ICU). The essential predictors that influence family satisfaction were identified using quantitative and qualitative analyses.

RESULTS

Seventy-three of the 227 patients' NOK who initially agreed completed the FS-ICU questionnaire (response rate 32.2%). The mean FS-ICU/total was 63.9 (standard deviation [SD], 30.8). The mean score for satisfaction with FS-ICU/dm was lower than the FS-ICU/care (62.1 [SD, 30.3) vs 65.4 (SD, 31.4); P < 0.001]. There was no difference in mean FS-ICU/total scores between survivors (n = 65; 89%) and non-survivors (n = 8, 11%). Higher patient Acute Physiology and Chronic Health Evaluation III score, female NOK and the patient dying in the ICU were independent predictors for FS-ICU/total score, while a telephone call at least once a day by an ICU doctor was related to family satisfaction for FS-ICU/dm.

CONCLUSIONS

There was low overall family satisfaction with ICU care and virtual communication strategies adopted during the COVID-19 pandemic. Efforts should be targeted for improving factors with virtual communication that cause low family satisfaction during the COVID-19 pandemic.

A Modified Delphi Process to Prioritize Experiences and Guidance Related to ICU Restricted Visitation Policies During the Coronavirus Disease 2019 Pandemic

To create evidence-based consensus statements for restricted ICU visitation policies to support critically ill patients, families, and healthcare professionals during current and future pandemics.

DESIGN

Three rounds of a remote modified Delphi consensus process.

SETTING

Online survey and virtual polling from February 2, 2021, to April 8, 2021.

SUBJECTS

Stakeholders (patients, families, clinicians, researchers, allied health professionals, decision-makers) admitted to or working in Canadian ICUs during the coronavirus disease 2019 pandemic.

MEASUREMENTS AND MAIN RESULTS

During Round 1, key stakeholders used a 9-point Likert scale to rate experiences (1-not significant, 9-significant impact on patients, families, healthcare professionals, or patient- and family-centered care) and strategies (1-not essential, 9-essential recommendation for inclusion in the development of restricted visitation policies) and used a free-text box to capture experiences/strategies we may have missed. Consensus was achieved if the median score was 7-9 or 1-3. During Round 2, participants used a 9-point Likert scale to re-rate experiences/strategies that did not meet consensus during Round 1 (median score of 4-6) and rate new items identified in Round 1. During Rounds 2 and 3, participants ranked items that reached consensus by order of importance (relative to other related items and experiences) using a weighted ranking system (0-100 points). Participants prioritized 11 experiences (e.g., variability of family's comfort with technology, healthcare professional moral distress) and developed 21 consensus statements (e.g., communicate policy changes to the hospital staff before the public, permit visitors at end-of-life regardless of coronavirus disease 2019 status, creating a clear definition for end-of-life) regarding restricted visitation policies.

CONCLUSIONS

We have formulated evidence-informed consensus statements regarding restricted visitation policies informed by diverse stakeholders, which could enhance patient- and family-centered care during a pandemic.