Family-centred care of patients admitted to the intensive care unit in times of COVID-19: A systematic review

Efficacy of Virtual Visitation in ICU During COVID-19 Pandemic: The ICU Visits Randomized Controlled Trial

OBJECTIVES

This study aimed to demonstrate the impact of virtual visits on the satisfaction of family members and the anxiety and depression of patients in the ICU during the COVID-19 pandemic.

DESIGN

A single-center, randomized controlled trial.

SETTING

This study was conducted from July 2021 to May 2022, in the Seoul National University Hospital.

PATIENTS

A total of 40 patients eligible for virtual visitation whose Richmond Agitation-Sedation Scale score was -2 or above were recruited and randomized into virtual visitation and usual care groups.

INTERVENTIONS

Virtual visitation began on the first day after ICU admission and continued until ICU discharge, lasting for a maximum of 7 days.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the satisfaction level of the family members with care and decision-making in the ICU, assessed using the Family Satisfaction-ICU (FS-ICU) 24-survey questionnaire. Secondary outcomes included patient anxiety and depression levels assessed using the Hospital Anxiety and Depression Scale (HADS), at the study enrollment after ICU admission and at the end of the study. After two patients were excluded due to clinical deterioration, 38 patients were ultimately analyzed, including 18 patients in the virtual visitation group and 20 patients in the usual care group. The FS-ICU 24 survey score was significantly higher in the virtual visitation group (89.1 ± 13.0 vs. 75.1 ± 17.7; p = 0.030). The reduction in HADS-Anxiety (59.4% vs. 15.39; p < 0.001) and HADS-Depression (64.5% vs. 24.2%; p < 0.001) scores between the two time points, from study enrollment after ICU admission to the end of the study was significantly larger in the virtual visitation group.

CONCLUSIONS

In the COVID-19 pandemic era, virtual visits to ICU patients helped reduce depression and anxiety levels of patients and increase the satisfaction of their family members. Enhancing access to virtual visits for family members and developing a consistent approach may improve the quality of care during another pandemic.

Implementation facilitators and barriers of person and family-centred emergency care

Background

At the time of the research, the nurses in the designated hospital's emergency department did not implement person- and family-centred care to the detriment of patients and families. They were, however, eager to embark on the implementation of the recommendations of the Registered Nurses Association of Ontario for person- and family-centred care.

Aim

This study therefore aimed to explore and describe the possible implementation facilitators and barriers prior to the use of the association's recommendations.

Setting

The study included eight nurses with different specialisation fields and more than 5 years of experience in an emergency department.

Methods

During focus group interviews with nurse participants, the domains of the Consolidated Framework for Implementation Research were used to explore whether the recommendations of the Registered Nurses Association of Ontario could be used to structure person- and family-centred care in the emergency department of the designated hospital in the Mpumalanga province in South Africa. The framework guided the deductive data analysis.

Results

The identified facilitators referred to a positive match between the recommendations and existing practice in the department. The barriers referred to the department's fast-paced work environment in which a combination of emergency and primary care is delivered.

Conclusion

One of the facilitators referred to the participants being used to ongoing training by and communication from management to support their adjustment to improvements. One of the barriers referred to the department's fast-paced work environment.

Contributions

The article contributes to practice improvement with a description of the use of frameworks to explore possible facilitators and barriers prior to endeavours to implement recommendations.

Communication intervention for families in adult intensive care units during COVID-19 pandemic: A systematic review

BACKGROUND

Restrictions on ICU family visitation during COVID-19 pandemic posed communication challenges for families, patients, and healthcare teams. Diverse approaches were used to overcome communication barriers. As ICUs begin to reinstate family visitation, it is timely to review the lessons learned from these interventions during the pandemic.

OBJECTIVES

To identify and evaluate content and qualities of the studies that describe communication interventions for families of adult ICU patients during the COVID-19 pandemic.

METHODS

Following the PRISMA guidelines, we searched PubMed, Embase, CINAHL, and Web of Science for studies that (1) involved communication intervention for families in adult ICU settings, (2) were published between January 2020 and September 2022, and (3) were published in English. We excluded studies that were not from peer-reviewed journal articles or in English.

RESULTS

Of 2,628 articles initially identified, we reviewed the 23 selected studies (20 non-experimental and 3 experimental studies). Most of the studies were published in 2022 (n = 14, 60.9 %) and conducted in Europe (n = 13, 56.5 %). Various communication methods (e.g., video calls, telephone, applications) were used to provide information, emotional support, and virtual access to patients and their families. Video calls were the most frequently used intervention. Many interventions included healthcare teams providing updates on the patient's condition or treatment to the family.

CONCLUSIONS

The COVID-19 pandemic prompted the adoption of diverse communication approaches for families in ICU settings, despite many limitations, including technical challenges. Insights gained from this experience will help expedite flexibility and diversity in designing communication interventions for ICU family members.

Effects of visit restriction in the COVID-19 pandemic: Experiences and perceptions of intensive care nurses

BACKGROUND

The visit restrictions imposed as a result of COVID-19 precluded the entrance of the patient's family into the confines of the intensive care unit.

AIM

This study evaluated the experiences of intensive care nurses (ICNs) regarding COVID-19 visit restrictions and their opinions on these restrictions.

STUDY DESIGN

From May 2023 to July 2023, semi-structured interviews with 15 ICNs from intensive care units in a tertiary public hospital in Türkiye were conducted. Data were analysed using qualitative content analysis with an inductive approach. Reporting of the study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

RESULTS

The analysis revealed two main themes, 'widespread negative impacts of visit restrictions' and 'adaptive strategies to the visitation ban', and seven sub-themes supporting the main themes. Nurses perceived that the visit restrictions imposed during the COVID-19 pandemic had a severe negative effect on patients, their relatives, themselves and the care environment. They also did not support visit restriction in future pandemics.

CONCLUSIONS

The COVID-19 visitation policy weakened the involvement of family members in patient care and created serious challenges in the intensive care setting. The study revealed an urgent need for patient-centred, family-sensitive and consistently applied protocols in future pandemics.

RELEVANCE TO CLINICAL PRACTICE

In future pandemics, strategies such as the benefit-benefit ratio of the visit, the provision and use of adequate personal protective equipment, and vaccination requirements should be considered in visiting decisions of patients hospitalized because of infection. Participation of nurses responsible for patient care in decisions regarding visitor practices should be supported.

Patient-centered care for mental health in patients with heart failure in the intensive care unit: A systematic review

AIM

To assess basic data for developing appropriate interventions by examining the effects of patient-centered care (PCC) on the mental health of patients with heart failure in the intensive care unit (ICU).

BACKGROUND

Patients with heart failure are frequently admitted to ICUs, and ICU stays are associated with prolonged mental health problems.

METHODS

We conducted a systematic review using the CINAHL, Cochrane Library, Embase, MEDLINE, PsycINFO, and gray literature databases. Inclusion criteria were studies with participants aged ≥18 years with heart failure in the ICU who received a PCC intervention, and studies that described the outcomes for mental health problems. Data were extracted from five selected studies published after 2020 and analyzed.

RESULTS

PCC is classified into three areas: comprehensive nursing, multidisciplinary disease management, and targeted motivational interviewing with conventional nursing. The two specific areas of focus for PCC regarding mental health were integrated mental healthcare and specific psychological nursing. Specific psychological nursing comprised relationship building, therapeutic communication, relaxation and motivational techniques, active therapeutic cooperation, psychological status evaluation, music therapy, and environmental management.

CONCLUSIONS

This review provides a distinctive understanding of multidisciplinary and multicomponent PCC interventions for patients with heart failure in the ICU as an effective approach for improving their mental health. Future PCC intervention strategies aimed at patients with heart failure in the ICU should consider their preferences and family participation.

Exploring critically ill patients' and their relatives' experiences of intensive care unit during COVID-19: A qualitative study

BACKGROUND

Admission to an intensive care unit has physiological and psychological consequences for patients and families, including the family's fear that the patient might die. The COVID-19 pandemic underlined this and furthermore involved visiting restrictions separating patients and families.

AIM

To explore how patients with confirmed COVID-19 and their relatives experienced an intensive care unit stay and its significance for family dynamics.

STUDY DESIGN

A qualitative study was performed during the spring of 2020. Five dyadic interviews were conducted with COVID-19 patients admitted to an intensive care unit and their relatives. The analysis was inspired by Hochman's dyadic analysis.

FINDINGS

The analysis revealed three themes: (1) From ill to critically ill: The trauma of separation and fear of losing loved ones; (2) The relatives' significant role in creating a shared coherent understanding of the admission in ICU due to COVID-19; (3) The nurses' roles as a go-between in maintenance of the family dynamic.

CONCLUSION

Separation challenged family function and destabilized family dynamics. Nurses provided emotional support, information about and contact with the patient and relatives. The patients' distorted perception of reality and lack of memory were reconstructed in new family narratives, which offered relief and stabilization of family dynamics. The nurses entered into a triad with the patient and relatives, which also contributed to maintaining a relational dynamic in the family.

RELEVANCE TO CLINICAL PRACTICE

Maintaining communication between health professionals, relatives and patients, and usage of virtual visits during intensive care unit stay can support the family relationship. Nurse therapeutic conversations might help families' in redefining their family dynamics after ICU admission.

The lived experiences of critical care nurses during the COVID-19 pandemic. A qualitative systematic review

OBJECTIVES

To critically synthesis the qualitative literature to understand the experiences of critical care nurses during the COVID-19 pandemic.

RESEARCH METHODOLOGY

A meta-aggregation systematic review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant online databases were searched using a wide range of keywords and subject headings. All qualitative studies were included to understand the lived experiences of critical care nurses in the intensive care unit during the COVID-19 pandemic. All studies were screened using a pre-eligibility screening criteria by three reviewers. The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research was used to provide methodological appraisal. The JBI method of meta-aggregation was used to extract, synthesize, and categorise the data.

FINDINGS

17 publications met the inclusion criteria. 136 individual findings were extracted, which were synthesised into 18 categories and eight synthesised findings. The eight synthesised findings included,1) Working as a team to adapt to the challenges of the pandemic, 2) Striving to provide patient centred care, 3) Coping with frequent deaths in the intensive care unit, 4) Challenges of supporting patients family from a distance, 5) The psychological impact of caring for critically unwell patients with COVID-19, 6) Working through the challenges of the intensive care unit setting during the pandemic, 7) The challenges of wearing personal protective equipment while undertaking patient care, 8) The impact of working in the intensive care unit during the pandemic on life at home..

CONCLUSION

This qualitative systematic review has given new insight into the lived experiences of critical care nurses. There were significant psychological and physical impacts on critical care nurses working during the COVID-19 pandemic. Therefore, improving psychological support, maintaining adequate staffing levels/skill mix to ensure basic nursing care can be completed, and the attendance of leadership/management staff is essential to ensure the retention of critical care nurses and achieve optimal patient outcomes.

IMPLICATIONS FOR CLINICAL PRACTICE

This review has highlighted implications for staff retention (counselling, skills development, contingency staffing), the need for improved management/leadership strategies and human resource policies to support critical care nurses when hospitals are in crisis. Additionally, the presence and needs of the family members of critically unwell patients' needs to be prioritised in the intensive care unit.

First and final farewells, disrupted family connections and loss: A collective case study exploring the impact of COVID-19 visitor restrictions in critical care

BACKGROUND

Patient and family-centred care is considered best practice. Such an approach is associated with high quality and positive experiences of care, and family presence at the bedside is encouraged and enabled. The COVID-19 pandemic, however, resulted in strictly enforced restrictions on hospital visitation, which threatened health professionals' ability to provide family-centred care.

AIM

To explore the impact of COVID-19 visitor restrictions on family relationships during critical illness at the end of life in the intensive care unit.

DESIGN

A retrospective collective case study approach was taken, using semi-structured interviews, conducted via telephone or Zoom, in accordance with COVID-19 restrictions.

SETTING/PARTICIPANTS

Two participant groups, bereaved next-of-kin of patients who died in the intensive care unit (n = 6) and critical care nurses (n = 3) from a major metropolitan hospital were included.

FINDINGS

Interviews with bereaved next-of-kin lasted 25-59 (mean = 41) minutes, and critical care nurse interviews lasted 31-52 (mean = 43) minutes. Inductive content analysis revealed five themes: (i) the first farewell, the significance not realised at the time; (ii) confusing rules and restrictions, which emphasised physical and created emotional barriers to family connections; (iii) inadequate communication, which further impacted next-of-kin; (iv) final farewells, which were rushed, emotional and afforded no privacy; and (v) reflecting back.

CONCLUSIONS

This collective case study demonstrates the profound impact visitor restrictions have had on bereaved next-of-kin and the wider family. A family-centred approach to care, protecting and prioritising family connection, and recognising the patient as a person who is part of a larger family unit must be emphasised.

IMPLICATIONS FOR CLINICAL PRACTICE

Critical care teams must consider their own approach to end-of-life care during times of visitor restrictions, finding new, flexible and innovative ways to improve communication, promote family-centred care, maintain the patient-family connection and facilitate end-of-life cultural customs, and rituals imperative to next-of-kin and the wider family unit.

Coping with the hospital environment during the COVID-19 pandemic: A qualitative study of the survivors' perspective during their stay at the ICU and inpatient ward

The COVID-19 pandemic has significantly affected the clinical practice of healthcare professionals. This study aimed to explore the perspectives of COVID-19 survivors regarding the healthcare they received during their stay in the Intensive Care Unit (ICU) and the inpatient COVID-19 ward. A qualitative case-study approach was implemented. Participants were recruited using non-probabilistic purposeful sampling strategy. Inclusion criteria included patients aged ≥18 years who received follow-up from the Pulmonology service at a Hospital in de North of Spain, were diagnosed with COVID-19 and bilateral pneumonia, and were admitted to the ICU before being transferred to a COVID-19 inpatient ward. Data was collected through in-depth interviews and researchers' field notes, and thematic analysis was performed. Techniques such as credibility, transferability, dependability, and confirmability were employed to ensure the trustworthiness of the data. A total of 25 individuals (six women) were included in the study. Three main themes emerged from the analysis: common challenges faced in both units, coping with the hospital stay, and developing strategies. Findings highlighted the need to improve information dissemination, individualize care, and enhance direct patient interaction. Moreover, the study shed light on the psychological impact of hospitalization and ICU experience, including feelings of loneliness, confinement, and the lack of memories from the ICU stay, as well as the influence of care and healthcare language. Finally, strategies such as keeping the mind occupied and maintaining self-discipline were identified as crucial during hospitalization. These findings provide valuable insights for healthcare professionals in delivering care to individuals with COVID-19 in the ICU and hospital ward settings.

Experiences with remote communication in adult intensive care units during the COVID-19 pandemic: a systematic review protocol

OBJECTIVE

The objective of this review is to explore the lived experiences of critically ill adults, their families, or health care professionals with remote communication in intensive care units (ICUs) during the COVID-19 pandemic.

INTRODUCTION

Family visiting restrictions in ICUs during the COVID-19 pandemic imposed significant challenges to communication between critically ill adults, their families, and the health care team. Evidence shows that several communication strategies were developed and implemented in ICUs during the COVID-19 pandemic to promote family engagement; however, the experiences of critically ill adults, their families, and health care professionals with these strategies are scattered across primary qualitative studies.

INCLUSION CRITERIA

This review will consider qualitative studies that include critically ill adults, their families, or health care professionals, focusing on their experiences with remote communication strategies in ICUs during the COVID-19 pandemic.

METHODS

This review will be conducted in accordance with JBI methodology. The search strategy will aim to locate both published and unpublished qualitative studies in English, Spanish, and Portuguese. Studies published after January 2020 will be included. Study selection, critical appraisal, and data extraction will be performed independently by 2 reviewers. Data will be presented in narrative format and synthesized using the JBI meta-aggregation process. A ConQual Summary of Findings will be presented.

REVIEW REGISTRATION

PROSPERO CRD42022383603.

Perceived Consequences of COVID-19 Restrictive Visitation Policy on Family Members at Rural Hospitals in Vhembe District: A Qualitative Study

From a public health standpoint, a stringent visitation policy was necessary during the COVID-19 pandemic, but it had unforeseen communicative and emotional health consequences for family members. This study explored family members' experiences regarding implementing a restricted visitation policy when a patient was admitted with COVID-19 at public hospitals in the Vhembe district. Researchers used an exploratory, descriptive, and contextual qualitative technique. Twelve family members made up the population. Unstructured telephone interviews were used to obtain the data, and open coding was used to analyse data. Ethics were consistently followed. Before taking part, participants provided verbal informed consent, acknowledging that they could withdraw from the study if necessary. Three themes emerged: inadequate measures for temporary communication channels and techniques, the mental health effects of COVID-19 admission, and poor/lack of standardised visitation policy during the COVID 19-pandemic. There was a need to balance safety from contracting COVID-19 infection and promoting family-centred care. Virtual visits through telecommunication solutions could reduce fear and anxiety as the family could be updated on the progress of the hospitalised relative. Alternatively, hospital managers must allocate a dedicated person in the unit to update families when they call and enquire about the conditions.

Supporting families of patients who die in adult intensive care: A scoping review of interventions

BACKGROUND

Families who perceive themselves as prepared for an impending death experience reduced psychological burden during bereavement. Understanding which interventions promote death preparedness in families during end-of-life care in intensive care will inform future intervention development and may help limit the burden of psychological symptoms associated with bereavement.

AIM

To identify and characterise interventions that help prepare families for the possibility of death in intensive care, incorporating barriers to intervention implementation, outcome variables and instruments used.

DESIGN

Scoping review using Joanna Briggs methodology, prospectively registered and reported using relevant guidelines.

DATA SOURCES

A systematic search of six databases from 2007 to 2023 for randomised controlled trials evaluating interventions that prepared families of intensive care patients for the possibility of death. Citations were screened against the inclusion criteria and extracted by two reviewers independently.

RESULTS

Seven trials met eligibility criteria. Interventions were classified: decision support, psychoeducation, information provision. Psychoeducation involving physician-led family conference, emotional support and written information reduced symptoms of anxiety, depression, prolonged grief, and post-traumatic stress in families during bereavement. Anxiety, depression, and post-traumatic stress were assessed most frequently. Barriers and facilitators to intervention implementation were seldom reported.

CONCLUSION

This review provides a conceptual framework of interventions to prepare families for death in intensive care, while highlighting a gap in rigorously conducted empirical research in this area. Future research should focus on theoretically informed, family-clinician communication, and explore the benefits of integrating existing multidisciplinary palliative care guidelines to deliver family conference within intensive care.

IMPLICATIONS FOR CLINICAL PRACTICE

Intensive care clinicians should consider innovative communication strategies to build family-clinician connectedness in remote pandemic conditions. To prepare families for an impending death, mnemonic guided physician-led family conference and printed information could be implemented to prepare families for death, dying and bereavement. Mnemonic guided emotional support during dying and family conference after death may also assist families seeking closure.

The lived experience by patients and family members of extracorporeal membrane oxygenation: A qualitative study

OBJECTIVE

To examine the lived experience of extracorporeal membrane oxygenation (ECMO) by patients and their families, and their relationship with intensive care clinicians.

RESEARCH METHODOLOGY

Semi-structured interviews were conducted with six patients who had received ECMO and with four of their family members. The data were analysed narratively using a constant comparative method.

SETTING

Patients were treated at a major acute care hospital in British Columbia between 2014 and 2021. ECMO was used either as a bridge to recovery or to organ transplant. Four had family members bedside throughout, while two had virtual visits due to COVID-19 infection control measures.

FINDINGS

ECMO was experienced through a triad of relationships between the patient, key family members and key clinicians. The strength, directionality and focus of these relationships shifted during therapy and realigned once ECMO was removed. The largest shift involved family members. Post-ECMO, patients relied almost entirely on spouses, adult children and clinical team members to reconstruct their experience. The connection between families and clinical team members was limited and changed little.

CONCLUSIONS

The lived experience of ECMO was complex in ways yet to be comprehensively reported in the literature. This technology had particular impact on family members when ECMO was used as a bridge to transplant and where run times extended to multiple weeks. COVID-19 infection control restrictions further complicated how this technology was experienced. Findings from this study highlight the importance of intensive care nurses recognising the critical role family members play as witnesses whose experiences later allow patients to make sense of their journey post-discharge.

Rectal and Tracheal Carriage of Carbapenemase Genes and Class 1 and 2 Integrons in Patients in Neurosurgery Intensive Care Unit

The spread of multidrug-resistant Gram-negative bacteria, which is associated with the distribution of beta-lactamase genes and class 1 and 2 integrons, is a global problem. In this study, in the Moscow neurosurgery intensive care unit (neuro-ICU), the high prevalence of the above-stated genes was found to be associated with intestinal and tracheal carriage. Seven-point prevalence surveys, which included 60 patients in the neuro-ICU, were conducted weekly in the period from Oct. to Nov. 2019. A total of 293 clinical samples were analyzed, including 146 rectal and 147 tracheal swabs; 344 Gram-negative bacteria isolates were collected. Beta-lactamase genes (n = 837) were detected in the isolates, including beta-lactamase blaTEM (n = 162), blaSHV (n = 145), cephalosporinase blaCTX-M (n = 228), carbapenemase blaNDM (n = 44), blaKPC (n = 25), blaOXA-48 (n = 126), blaOXA-51-like (n = 54), blaOXA-40-like (n = 43), blaOXA-23-like (n = 8), and blaVIM (n = 2), as well as class 1 (n = 189) and class 2 (n = 12) integrons. One extensively drug-resistant Klebsiella pneumoniae strain (sequence type ST39 and capsular type K23), simultaneously carried beta-lactamase genes, blaSHV-40 and blaTEM-1B, three carbapenemase genes, blaNDM, blaKPC, and blaOXA-48, the cephalosporinase gene blaCTX-M, and two class 1 integrons. Before this study, such heavily armed strains have not been reported, suggesting the ongoing evolution of antibiotic resistance.