Open visitation policies and practices in US ICUs: can we ever get there?

An environmental scan of visitation policies in Canadian intensive care units during the first wave of the COVID-19 pandemic

Purpose

In response to the rapid spread of SARS-CoV-2, hospitals in Canada enacted temporary visitor restrictions to limit the spread of COVID-19 and preserve personal protective equipment supplies. This study describes the extent, variation, and fluctuation of Canadian adult intensive care unit (ICU) visitation policies before and during the first wave of the COVID-19 pandemic.

Methods

We conducted an environmental scan of Canadian hospital visitation policies throughout the first wave of the pandemic. We conducted a two-phased study analyzing both quantitative and qualitative data.

Results

We collected 257 documents with reference to visitation policies (preCOVID, 101 [39%]; midCOVID, 71 [28%]; and lateCOVID, 85 [33%]). Of these 257 documents, 38 (15%) were ICU-specific and 70 (27%) referenced the ICU. Most policies during the midCOVID/lateCOVID pandemic period allowed no visitors with specific exceptions (e.g., end-of-life). Framework analysis revealed five overarching themes: 1) reasons for restricted visitation policies; 2) visitation policies and expectations; 3) exceptions to visitation policy; 4) patient and family-centred care; and 5) communication and transparency.

Conclusions

During the first wave of the COVID-19 pandemic, most Canadian hospitals had public-facing visitor restriction policies with specific exception categories, most commonly for patients at end-of-life, patients requiring assistance, or COVID-19 positive patients (varying from not allowed to case-by-case). Further studies are needed to understand the consistency with which visitation policies were operationalized and how they may have impacted patient- and family-centred care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12630-021-02049-4.

Doing time in an Australian ICU; the experience and environment from the perspective of patients and family members

BACKGROUND

The intensive care environment and experiences during admission can negatively impact patient and family outcomes and can complicate recovery both in hospital and after discharge. While their perspectives based on intimate experiences of the environment could help inform design improvements, patients and their families are typically not involved in design processes. Rather than designing the environment around the needs of the patients, emphasis has traditionally been placed on clinical and economic efficiencies.

OBJECTIVE

The main objective was to inform design of an optimised intensive care bedspace by developing an understanding of how patients and their families experience the intensive care environment and its impact on recovery.

METHODS

A qualitative descriptive study was conducted with data collected in interviews with 17 intensive care patients and seven family members at a large cardiothoracic specialist hospital, analysed using a framework approach.

RESULTS

Participants described the intensive care as a noisy, bright, confronting and scary environment that prevented sleep and was suboptimal for recovery. Bedspaces were described as small and cluttered, with limited access to natural light or cognitive stimulation. The limited ability to personalise the environment and maintain connections with family and the outside world was considered especially problematic.

CONCLUSIONS

Intensive care patients described features of the current environment they considered problematic and potentially hindering their recovery. The perspective of patients and their families can be utilised by researchers and developers to improve the design and function of the intensive care environment. This can potentially improve patient outcomes and help deliver more personalised and effective care to this vulnerable patient population and their families.

Implementation and sustainment strategies for open visitation in the intensive care unit: A multicentre qualitative study

Objective

Open visitation in adult intensive care units has been associated with improved family and patient outcomes. However, worldwide adoption of this practice has been slow and reasons for this are unclear. This study documents barriers and strategies for implementing and sustaining open visitation in adult intensive care units in the United States experienced by nursing leadership.

Research design

Qualitative approach using grounded theory.

Participants

Nurse leaders in adult intensive care units with open visitation.

Setting

Magnet® or Pathway to Excellence® designated hospitals in the United States.

Methods

Semi structured interviews were conducted with 19 nurse leaders from 15 geographically dispersed hospitals. Interviews were recorded, transcribed and imported into Atlas.ti qualitative software for analysis. Grounded theory constant comparison analysis was used for coding and category development.

Findings

The analysis revealed three barriers; nursing attitudes and clinical and nonclinical barriers. Strategies to overcome these barriers were empathy, evidence-based practice, models of care, shared governance, nurse discretion, security and family spaces.

Conclusion

Intensive care nursing leadership experienced distinct barriers and strategies during pre-implementation, implementation and sustainment of open visitation. Other nursing leaders interested in open visitation can use these findings as they plan this transition in their intensive care units.

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.

The intensive care unit: How to make this unfriendly environment geriatric-friendly

Patients 80 years old or older are increasingly being admitted to intensive care units, particularly in western countries, where life expectancy is constantly increasing. The benefits of intensively treating critically ill elderly patients are uncertain. The high mortality rate in the presence of underlying chronic diseases is a factor. More generally, frailty, defined as an impaired resilience following a health stressor event, must be taken into account. No consensus exists on the risk-benefit ratio to admit octogenarians to the ICU. Treatment decisions should account for life expectancy but also tailored to the needs and wishes of patients and next-of-kins. The cohort of elderly patients is known to be the most vulnerable to functional decline and cognitive impairment, including neuropsychological complications, such as delirium.. Interventions directed at reducing the incidence of delirium may mitigate brain injury associated with critical illness, potentially being the single most effective intervention in this population. A multimodal approach to analgesia should be considered to avoid untreated pain and its consequences. Sleep protocols can effectively reduce the risk of delirium. Notably, the deployment of "sleep bundles" (regular sleep-wake rhythms, reduced night-time light, noise control strategies), may be helpful. As well, adequate nutritional support, spontaneous awakening trials, early mobilization, and physical therapy are crucial to prevent physical deconditioning. The psychological consequences of critical illness for both patients and caregivers are also being increasingly recognized. Attention to the needs of families is essential, due to its positive effects on patients and as a quality improvement goal by itself. Death and dying in the ICU is a more frequent outcome in the elderly population. A real culture for the management of distress and grieving is a required skill for the ICU staff. Privacy and adequate palliative care should be contemplated for an ethical and comfortable end of life.

Parents and nurses telling their stories: the perceived needs of parents caring for critically ill children at the Kilimanjaro Christian Medical Centre in Tanzania

Background

Parents have significant responsibility in the care of their critically ill children who have been admitted to the intensive care unit (ICU). When staying with their children in the hospital, they also have particular needs that should be adequately acknowledged and responded to by healthcare providers. Moreover, when their needs are not identified and addressed, parents may experience stress and anxiety as a result. This study describes the needs of parents caring for hospitalized critically ill children, as perceived by parents and nurses.

Methods

This study used a descriptive qualitative research design. Five focus group discussions with nurses and parents of critically ill children, who were purposefully recruited, were conducted at the Kilimanjaro Christian Medical Centre Hospital. A qualitative content analysis guided the analysis of the data.

Results

Two themes emerged from the perceptions of parents and nurses about the needs of parents caring for hospitalized critically ill children. These were: "engaging parents in the care of their children" and "receiving psychosocial support". Both parents and nurses identified the importance of providing adequate information about their children's progress, encouraging and involving parents in the care of their children and having flexible visiting time for parents was vital when caring for critically ill children.

Conclusions

This study provides an in-depth understanding of parents' needs when caring for critically ill children in the hospital setting. Nurses caring for these children should understand the needs of parents and integrate the parents into the daily care of their children. Nurses should also continuously support, inform and engage parents during child-caring procedures. Finally, visiting times for intensive care units should be flexible and allow more time for parents to connect with their hospitalized children.

Family members' beliefs and attitudes towards visiting policy in the intensive care units of Ghana

AIM

This study aimed to investigate family members' beliefs and attitudes towards the visiting policies of intensive care units (ICUs).

DESIGN

It employed a descriptive cross-sectional quantitative design.

METHOD

This study recruited four public hospitals in Ghana with a sample of 200 family members. The study was conducted using a self-administered questionnaire. The data were collected and analysed with SPSS version 16.

RESULTS

This study revealed that while family members believed in the beneficial effect of adhering to open visiting policies in ICUs, their attitudes were sceptical and restrictive. Most family members preferred the acceptable number of visitors within 24 hr to be two, and according to them, only one person should be allowed to enter at a time. There was a meaningful relationship between the families' beliefs and religion (p = 0.02), educational level (p = 0.03) and family status (p = 0.02). Furthermore, a meaningful relationship was also observed between the families' attitudes and status (p = 0.04) and their level of education (p = 0.05). The studied family members showed concern in this regard and did not want the community style of visiting to be implemented, which could hinder patients' recovery.

Implementation and Operational Analysis of an Interactive Intensive Care Unit within a Smart Health Context

In the context of hospital management and operation, Intensive Care Units (ICU) are one of the most challenging in terms of time responsiveness and criticality, in which adequate resource management and signal processing play a key role in overall system performance. In this work, a context aware Intensive Care Unit is implemented and analyzed to provide scalable signal acquisition capabilities, as well as to provide tracking and access control. Wireless channel analysis is performed by means of hybrid optimized 3D Ray Launching deterministic simulation to assess potential interference impact as well as to provide required coverage/capacity thresholds for employed transceivers. Wireless system operation within the ICU scenario, considering conventional transceiver operation, is feasible in terms of quality of service for the complete scenario. Extensive measurements of overall interference levels have also been carried out, enabling subsequent adequate coverage/capacity estimations, for a set of Zigbee based nodes. Real system operation has been tested, with ad-hoc designed Zigbee wireless motes, employing lightweight communication protocols to minimize energy and bandwidth usage. An ICU information gathering application and software architecture for Visitor Access Control has been implemented, providing monitoring of the Boxes external doors and the identification of visitors via a RFID system. The results enable a solution to provide ICU access control and tracking capabilities previously not exploited, providing a step forward in the implementation of a Smart Health framework.

Patient Admission Preferences and Perceptions

INTRODUCTION

Understanding patient perceptions and preferences of hospital care is important to improve patients' hospitalization experiences and satisfaction. The objective of this study was to investigate patient preferences and perceptions of hospital care, specifically differences between intensive care unit (ICU) and hospital floor admissions.

METHODS

This was a cross-sectional survey of emergency department (ED) patients who were presented with a hypothetical scenario of a patient with mild traumatic brain injury (TBI). We surveyed their preferences and perceptions of hospital care related to this scenario. A closed-ended questionnaire provided quantitative data on patient preferences and perceptions of hospital care and an open-ended questionnaire evaluated factors that may not have been captured with the closed-ended questionnaire.

RESULTS

Out of 302 study patients, the ability for family and friends to visit (83%), nurse availability (80%), and physician availability (79%) were the factors most commonly rated "very important," while the cost of hospitalization (62%) and length of hospitalization (59%) were the factors least commonly rated "very important." When asked to choose between the ICU and the floor if they were the patient in the scenario, 33 patients (10.9%) choose the ICU, 133 chose the floor (44.0%), and 136 (45.0%) had no preference.

CONCLUSION

Based on a hypothetical scenario of mild TBI, the majority of patients preferred admission to the floor or had no preference compared to admission to the ICU. Humanistic factors such as the availability of doctors and nurses and the ability to interact with family appear to have a greater priority than systematic factors of hospitalization, such as length and cost of hospitalization or length of time in the ED waiting for an in-patient bed.