When the Letter “F” Meets the Letter “D”: Beneficial Impact of Open Visiting and Family Presence on Incidence of Delirium Among ICU Patients*

Practices of the ABCDEF care bundle in intensive care units as reported by nurses: A cross-sectional study from Turkey

BACKGROUND

Recent critical care guidelines recommended the evidence-based ABCDEF care bundle for intensive care unit (ICU) patients. However, limited information is available on the implementation of the bundle in Turkish ICUs.

AIM

To assess the current practices of the ABCDEF care bundle as reported by ICU nurses.

STUDY DESIGN

A cross-sectional study using a web-based survey was conducted. Researchers invited nurses with at least 1 year of ICU experience to participate by sending the link to the research questionnaires they created in Google Forms to the one ICU nurse association and one communication group of which they are members.

RESULTS

A total of 342 ICU nurses completed the survey. Although 92% of the participants performed pain assessments in their ICUs, 52.7% reported not using protocols. Based on the responses of the nurses, spontaneous awakening and breathing trials are performed in 88.8% and 92.4%, respectively, of ICUs. Fewer than half of the participants reported following a sedation protocol in their ICUs. Only 54.7% of ICU nurses surveyed reported routinely monitoring patients for delirium. It was reported that early mobilization was practised in 68.7% of ICUs, but non-ventilated patients were mobilized more frequently (70.2%), and 9.7% of ICUs had mobilization teams. Family members were actively involved in 95% of ICUs; however, 9.7% used dedicated staff to support families and 3.5% reported that their unit was open 24 h/day for visits.

CONCLUSIONS

While the implementation of most pain and sedation evaluations in ICUs were reported by nurses, many of them did not use structured delirium assessments. There is a need to encourage early mobilization programs and family participation.

RELEVANCE TO CLINICAL PRACTICE

Health institutions can improve patient care and outcomes by establishing and standardizing a protocol for each component of the ABCDEF care bundle in ICUs.

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

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

Implementation of ABCDEF care bundle in intensive care units: A cross-sectional survey

BACKGROUND

Delirium affects up to 80% of patients in intensive care units (ICUs) and is associated with higher mortality, physical dependence, and health care costs. The 2018 pain, agitation, delirium, immobility, and sleep guideline recommended ABCDEF care bundle for delirium prevention and management. However, limited information is available regarding the adoption of the care bundle in ICUs in Mainland China.

AIMS AND OBJECTIVES

To assess the current implementation of the ABCDEF care bundle for delirium prevention as reported by ICU nurses in Mainland China.

DESIGN

A cross-sectional study was conducted.

METHODS

A cross-sectional online survey using a validated questionnaire about the practices of the ABCDEF care bundle was conducted among 334 registered nurses in 167 ICUs of 65 cities in Mainland China.

RESULTS

Almost 50% of the sampled ICU nurses were unaware of the ABCDEF care bundle, though 86.83% of the surveyed ICUs implemented pain assessments and 95.51% implemented sedation assessments. Nearly half (46.41%) of the surveyed ICUs performed routine spontaneous awaking trials, with 21.26% performing them daily. Spontaneous breathing trials were performed in 38.32% of the surveyed ICUs. Only 47% of the surveyed ICUs routinely monitored patients for delirium. About one-third (38.35%) of the surveyed ICUs were supported by specialist teams that implemented the mobilization programmes. Most ICUs restricted the duration of family visits per day (<0.5 hour: 61.67%; 0.5-2 hours: 23.65%; >2 hours: 3.29%) and only 28.14% of the surveyed ICUs employed dedicated staff to support the families.

CONCLUSIONS

Although most of the surveyed ICUs implemented pain and sedation assessments, many of them did not implement structured delirium assessments. Early mobilization programmes and family participation should be encouraged.

RELEVANCE TO CLINICAL PRACTICE

Promoting the uses of a reliable delirium assessment tool such as Confusion Assessment Method for Intensive Care Unit patients, building an early mobilization team, and engaging family caregivers in the care plan may contribute to improved patients' clinical outcomes.

Is Open Visitation Really "Open" in Adult Intensive Care Units in the United States?

BACKGROUND

Evidence indicates that open visitation in adult intensive care units is a best practice for patient- and family-centered care, and nurses substantially influence such visitation patterns. However, it is unclear whether intensive care units in Magnet and Pathway to Excellence (MPE) facilities nationwide implement this in practice.

OBJECTIVE

To describe current national visitation practices in adult intensive care units and determine whether they have changed since the last national study, which used data from 2008 to 2009.

METHODS

From February through April 2018, websites of MPE hospitals were reviewed in order to identify their adult intensive care unit visitation policy. If this information was unavailable online, the hospital was telephoned to obtain the policy. From May through August 2018, follow-up telephone calls were made to hospitals that reported open visitation, during which intensive care unit nurses at the hospitals were asked to verify that the policy did not restrict visiting hours or the number, type, or age of visitors.

RESULTS

Among the 536 MPE hospitals contacted, 51% (n = 274) indicated that they allowed open visitation. Further examination, however, revealed that 64% (n = 175) restricted the number (68.2%), age (59.5%), or type (4.4%) of visitors, or visiting hours (19.8%). Only 18.5% of MPE hospitals (n = 99) allowed unrestricted visitation.

CONCLUSION

This study suggests a lack of progress toward implementing open visitation in adult intensive care units nationwide. Research on MPE hospitals that have adopted truly open visitation policies is needed to identify successful methods for implementing and sustaining open visitation.

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

OBJECTIVES

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

DATA SOURCES

Medline, Scopus, and Web of Science.

STUDY SELECTION

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

DATA EXTRACTION

Duplicate independent review and data abstraction.

DATA SYNTHESIS

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

CONCLUSIONS

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