Patient and Family Engagement in the ICU. Untapped Opportunities and Underrecognized Challenges

Eleven years impact of a stepwise educational program on healthcare associated infections and antibiotics consumption in an intensive care unit of a tertiary hospital in Brazil

BACKGROUND

Hospital acquired infections (HAI) and liberal use of broad-spectrum antibiotics are common in intensive care unit(ICU)s of low-middle income countries. We investigated the long-term association of a stepwise multifaceted educational program with the incidence of HAIs and antibiotics use in a Brazilian ICU. We also evaluated the program's cost impact.

METHODS

We retrieved data from a prospective daily collected database of a twelve bedrooms ICU, all admitted patients within a period of eleven years were enrolled.

FINDINGS

From 03/15/2007 to 09/11/2019, we admitted 3059 patients where 2406 (79%) survived the ICU stay. Median age was 51 years-old, and median SAPS3 was 53. The initial density of catheter related blood infection (4.3 events / 1000 patients-day), urinary tract infection (9.2 event / 1000 patients-day) and ventilator associated pneumonia (54.9 events / 1000 patients-day) felt during the observed period to (0.35 events / 1000 patients-day), (0 events / 1000 patients-day), and (1.5 events / 1000 patients-day) respectively. The days of antibiotic therapy also decreased from 797.9 days of therapy / 1000 patients day to 292.3 days of therapy / 1000 patients day. The total cost per patient also decreased. The adjusted mortality rate was steady during the studied period from 23.2% to 22.9%.

INTERPRETATION

A stepwise multifaceted educational program is an effective way to reduce hospital-associated infections, improve the rational use of antibiotics, and reduce costs. This impact occurred in a long term, and is probably consistent.

Patient-important upper gastrointestinal bleeding in the ICU: A mixed-methods study of patient and family perspectives

INTRODUCTION

The objective of this study was to create a definition of patient-important upper gastrointestinal bleeding during critical illness as an outcome for a randomized trial.

DESIGN

This was a sequential mixed-methods qualitative-dominant multi-center study with an instrument-building aim. In semi-structured individual interviews or focus groups we elicited views from survivors of critical illness and family members of patients in the intensive care unit (ICU) regarding which features indicate important gastrointestinal bleeding. Quantitative demographic characteristics were collected. We analyzed qualitative data using inductive content analysis to develop a definition for patient-important upper gastrointestinal bleeding.

SETTING

Canada and the United States.

PARTICIPANTS

51 ICU survivors and family members of ICU patients.

RESULTS

Participants considered gastrointestinal bleeding to be important if it resulted in death, disability, or prolonged hospitalization. The following also signaled patient-important upper gastrointestinal bleeding: blood transfusion, vasopressors, endoscopy, CT-angiography, or surgery. Whether an intervention evinced concern depended on its effectiveness, side-effects, invasiveness and accessibility; contextual influences included participant familiarity and knowledge of interventions and trust in the clinical team.

CONCLUSIONS

Survivors of critical illness and family members described patient-important upper gastrointestinal bleeding differently than current definitions of clinically-important upper gastrointestinal bleeding.

Early mobility and family partnerships in the intensive care unit: A scoping review of reviews

BACKGROUND

Critical illness significantly impacts the well-being of patients and families. Previous studies show that family members are willing to participate in patient care. Involving families in early mobility interventions may contribute to improved recovery and positive outcomes for patients and families.

AIM

In this scoping review, we investigated early mobility interventions for critically ill patients evaluated in randomized controlled trials and the extent to which family engagement in those interventions are reported in the literature.

STUDY DESIGN

In this scoping review of reviews, EMBASE, CINAHL, PubMed and Cochrane Central databases were searched in October 2019 and updated in February 2022. Systematic reviews were included and assessed using A MeaSurement Tool to Assess Systematic Reviews (AMSTAR) 2. Data were synthesized using a narrative approach. PRISMA-ScR guidelines were adhered to for reporting.

RESULTS

Thirty-three reviews were included which described a range of early mobility interventions for critically ill patients; none explicitly mentioned family engagement. Almost half of the reviews were of low or critically low quality. Insufficient detail of early mobility interventions prompted information to be extracted from the primary studies.

CONCLUSIONS

There are a range of early mobility interventions for critically ill patients but few involve families. Given the positive outcomes of family participation, and family willingness to participate in care, there is a need to explore the feasibility and acceptability of family participation in early mobility interventions.

RELEVANCE TO CLINICAL PRACTICE

Family engagement in early mobility interventions for critically ill patients should be encouraged and supported. How to best support family members and clinicians in enacting family involvement in early mobility requires further investigation.

Family Members' Engagement in Symptom Communication, Assessment, and Management in the Intensive Care Unit: A Qualitative Study

BACKGROUND

Opportunities for communication and participation in decision making are limited for critically ill patients, but family members serving as surrogates enable empowerment of these patients.

OBJECTIVE

The aim of this study was to explore family members' engagement in symptom communication in the intensive care unit.

METHODS

A qualitative descriptive design using fieldwork methodology with triangulation of participant observation and individual interviews was conducted. Nine mechanically ventilated patients were observed in interaction with family members and clinicians in the intensive care unit. Six of the observed patients, 6 family members, and 9 clinicians were interviewed after participant observation. Field notes and transcripts were analyzed using Braun and Clarke's method of thematic analysis.

RESULTS

Family members engaged actively in symptom communication, assessment, and management, and there were barriers and facilitators to family engagement. Three main themes and 9 subthemes describing family engagement emerged: (1) intermediary role (recognize and report symptoms, provide patient information, and assist in communication), (2) independent role (provide familiarity, manage symptoms, and promote patient communication), and (3) conditions for family engagement (intensive care unit environment, relationship with the patient, and patient preferences).

DISCUSSION

Family members have unique knowledge of the patient that differs from and complement the competence of the staff, and might contribute to improved symptom communication. Future research should examine how family members can contribute to symptom communication, assessment, and management.

Patient and family engagement in Danish intensive care units: A national survey

BACKGROUND

Patient and family engagement in the intensive care unit increases the quality of care and patient safety.

AIM

The aim of our study was to describe current practice and experiences of contemporary patient and family engagement in the intensive care unit at the individual level, the organizational level, and in the research process according to critical care nurses.

DESIGN/METHOD

We conducted a national qualitative survey of intensive care units in Denmark from 5th May-5th June 2021. Questionnaires were piloted and sent to intensive care nurse specialists and research nurses at 41 intensive care units, allowing one respondent per unit. All respondents were provided with written information about the study by email, and by activating the survey link, they accepted participation.

RESULTS

Thirty-two nurses responded to the invitation, 24 completed and 8 partially completed the survey, yielding a response rate of 78%. At the individual level, 27 respondents stated that they involved patients and 25 said they involved family in daily treatment and care. At the organizational level, 28 intensive care units had an overall strategy or guideline for patient and family engagement, and 4 units had established a PFE panel. And, finally, 11 units engaged patients and families in the research process.

CONCLUSIONS

Our survey suggested that patient and family engagement was implemented to some degree at the individual level, organizational level, and in the research process, but only 4 units had established a PFE panel at the organizational level, which is key to engagement.

RELEVANCE TO CLINICAL PRACTICE

Patient engagement increases when patients are more awake, and family engagement increases when patients are unable to participate. Engagement increases when patient and family engagement panels are implemented.

Understanding and Managing Anxiety Sensitivity During Critical Illness and Long-Term Recovery

Anxiety sensitivity is a fear of symptoms associated with anxiety (eg, rapid respiration and heart rate, perspiration), also known as "fear of fear." This fear is a misinterpretation of nonthreatening symptoms as threatening across 3 domains: physical ("When my heart rate increases, I'm afraid I may have a heart attack"), social ("If people see me perspire, I fear they will negatively evaluate me"), and cognitive ("When I feel these symptoms, I fear it means I'm going crazy or will lose control and do something dangerous like disconnect my IV"). These thoughts stimulate the sympathetic nervous system, resulting in stronger sensations and further catastrophic misinterpretations, which may spiral into a panic attack. Strategies to address anxiety sensitivity include pharmacologic and nonpharmacologic interventions. In intensive care unit settings, anxiety sensitivity may be related to common monitoring and interventional procedures (eg, oxygen therapy, repositioning, use of urine collection systems). Anxiety sensitivity can be a barrier to weaning from mechanical ventilation when patients are uncomfortable following instructions to perform awakening or breathing trials. Fortunately, anxiety sensitivity is a malleable trait with evidence-based intervention options. However, few health care providers are aware of this psychological construct and available treatment. This article describes the nature of anxiety sensitivity, its potential impact on intensive care, how to assess and interpret scores from validated instruments such as the Anxiety Sensitivity Index, and treatment approaches across the critical care trajectory, including long-term recovery. Implications for critical care practice and future directions are also addressed.

Nurses' Perceptions of Intensive Care Unit Orientation Patient Education Pamphlet

Background

Critical illness is a stressful time for patients and their support networks. Although patient-directed educational material to improve the understanding of critical illness exists, both patients and staff members are often unaware of these resources or how to find them.

Objectives

We aimed to evaluate the impact of the implementation of the American Thoracic Society's (ATS) "Managing the Intensive Care Unity (ICU) Experience: A Proactive Guide for Patients and Families", an ICU orientation pamphlet, on nurses' perceptions of the availability and effectiveness of patient and family educational resources.

Methods

In a safety-net urban institution, we surveyed medical ICU (MICU) nurses in February 2021 regarding their perceptions of the availability of patient and family educational materials and the time and quality of communication with families of critically ill patients. We then introduced the MICU nurses to the ATS ICU orientation pamphlet to complement patient and family education. Quick response (QR) codes were created, linking to the online versions of the ICU pamphlet, and made available in waiting rooms. Printed copies of the pamphlet were provided to families in the ICU introductory packet upon patient MICU admission. We informed nurses regarding the pamphlet content, website, and QR codes. A postintervention survey was administered 11 months after the initial survey. Changes between pre and postintervention responses were analyzed for significant differences. Debriefing sessions with the MICU nurses were conducted, and subsequent discussions identified opportunities to improve the available educational resources.

Results

At baseline, 28 of 67 (42%) MICU nurses responded to the survey. Although all nurses provided verbal education to patients and families, only 18% reported knowing about and using additional resources to supplement this education. The postintervention survey was completed by 39% of nurses; 39% of them reported using additional materials to supplement patient and family education. Reported awareness of the ATS ICU pamphlet increased from 4% before implementation to 23% after implementation (P = 0.04). MICU nurses offered suggestions to improve the pamphlet, which thematically fell into three categories: 1) opportunities to alter the ICU pamphlet, 2) opportunities to provide the pamphlet in varied formats, and 3) opportunities to add additional education topics.

Conclusions

Informing nurses about the ICU pamphlet improved the acceptance and use of the materials, but it was still not accepted by many nurses. Barriers to ICU nurses using patient education resources should be explored to facilitate quality materials reaching patients and complementing patient communication. QR codes may have offered a way to disseminate educational materials to patients and families in a manner not previously considered. The process of evaluating the ICU pamphlet for our institution led to a broader discussion of additional needs for patient and family educational materials for our patient population. We encourage institutions to evaluate the sufficiency of their patient and family educational materials for similar local benefits.

What counts as patient-important upper gastrointestinal bleeding in the ICU? A mixed-methods study protocol of patient and family perspectives

INTRODUCTION

Clinically important upper gastrointestinal bleeding is conventionally defined as bleeding accompanied by haemodynamic changes, requiring red blood cell transfusions or other invasive interventions. However, it is unclear if this clinical definition reflects patient values and preferences. This protocol describes a study to elicit views from patients and families regarding features, tests, and treatments for upper gastrointestinal bleeding that are important to them.

METHODS AND ANALYSIS

This is a sequential mixed-methods qualitative-dominant multi-centre study with an instrument-building aim. We developed orientation tools and educational materials in partnership with patients and family members, including a slide deck and executive summary. We will invite intensive care unit (ICU) survivors and family members of former ICU patients to participate. Following a virtual interactive presentation, participants will share their perspectives in an interview or focus group. Qualitative data will be analysed using inductive qualitative content analysis, wherein codes will be derived directly from the data rather than using preconceived categories. Concurrent data collection and analysis will occur. Quantitative data will include self-reported demographic characteristics. This study will synthesise the values and perspectives of patients and family members to create a new trial outcome for a randomised trial of stress ulcer prophylaxis. This study is planned for May 2022 to August 2023. The pilot work was completed in Spring 2021.

ETHICS AND DISSEMINATION

This study has ethics approval from McMaster University and the University of Calgary. Findings will be disseminated via manuscript and through incorporation as a secondary trial outcome on stress ulcer prophylaxis.

TRIAL REGISTRATION NUMBER

NCT05506150.

Development and Validity of the Japanese Version of the Questionnaire on Factors That Influence Family Engagement in Acute Care Settings

There exists an international consensus on the importance of family-centered care (FCC) in intensive care settings and the evaluation of collaboration between nurses and families; however, FCC is currently practiced blindly in Japan. In this study, we developed a Japanese version of the questionnaire, Factors that Influence Family Engagement (QFIFE-J) and examined its reliability and validity. A web-based survey was conducted with 250 nurses working in the intensive care unit (ICU). Exploratory and validatory factor analyses were used to ascertain factor validity. Criterion-related validity was tested using correlation analysis with the ICU Nurses’ Family Assistance Practice Scale. Internal consistency and reproducibility were verified for reliability. Following exploratory and confirmatory factor analyses, a 15-item measure emerged comprising four factors: “ICU environment”, “nurses’ attitudes”, “nurses’ workflow”, and “patient acuity”. Confirmatory factor analyses showed a generally good fit. Cronbach’s α for the overall scale was 0.78, indicating acceptable internal consistency. The intraclass coefficient for test–retest reliability was 0.80. It was found that the QFIFE-J was reliable and valid and may help determine the factors that promote or inhibit FCC. Additionally, this study has also clarified the current status and family support related issues in ICUs in Japan.

An Exploration of Critical Care Professionals' Strategies to Enhance Daily Implementation of the Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia and Sedation; Delirium Assess, Prevent, and Manage; Early Mobility and Exercise; and Family Engagement and Empowerment: A Group Concept Mapping Study

The goals of this exploratory study were to engage professionals from the Society for Critical Care Medicine ICU Liberation Collaborative ICUs to: 1) conceptualize strategies to enhance daily implementation of the Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle from different perspectives and 2) identify strategies to prioritize for implementation.

DESIGN

Mixed-methods group concept mapping over 8 months using an online method. Participants provided strategies in response to a prompt about what was needed for successful daily ABCDEF bundle implementation. Responses were summarized into a set of unique statements and then rated on a 5-point scale on degree of necessity (essential) and degree to which currently used.

SETTING

Sixty-eight academic, community, and federal ICUs.

PARTICIPANTS

A total of 121 ICU professionals consisting of frontline and leadership professionals.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A final set of 76 strategies (reduced from 188 responses) were suggested: education (16 strategies), collaboration (15 strategies), processes and protocols (13 strategies), feedback (10 strategies), sedation/pain practices (nine strategies), education (eight strategies), and family (five strategies). Nine strategies were rated as very essential but infrequently used: adequate staffing, adequate mobility equipment, attention to (patient's) sleep, open discussion and collaborative problem solving, nonsedation methods to address ventilator dyssynchrony, specific expectations for night and day shifts, education of whole team on interdependent nature of the bundle, and effective sleep protocol.

CONCLUSIONS

In this concept mapping study, ICU professionals provided strategies that spanned a number of conceptual implementation clusters. Results can be used by ICU leaders for implementation planning to address context-specific interdisciplinary approaches to improve ABCDEF bundle implementation.

Interventions using digital technology to promote family engagement in the adult intensive care unit: An integrative review

BACKGROUND

Family engagement is a key component of safe and effective care in the intensive care unit (ICU). As the COVID-19 pandemic has accelerated the adoption of digital technologies in healthcare settings, it is important to review the current science of family engagement interventions in the ICU using digital technology.

OBJECTIVES

This integrative review aimed to identify and evaluate studies that used digital technology to promote family engagement in adult ICUs and synthesize study findings.

METHODS

Following the methodology of Whittemore and Knafl, PubMed, CINAHL, Web of Science, and Scopus were searched. We included studies conducted in the adult ICU setting; involved family engagement during ICU stay; and used digital technology to engage family members. We excluded studies that were not peer-reviewed or in English. Study findings were assessed using the model of family engagement in the ICU RESULTS: Of 2702 articles, 15 articles were analyzed. Various technologies (e.g., web-, tablet-, or SMS-based tools, video-conferencing, etc.) were used to provide information; augment the decision-making process; provide virtual access to family conferences or interdisciplinary rounds. While varying among interventions, "Information sharing" and "activation and participation" were most commonly addressed within the family engagement model. In studies that addressed the components of family engagement more comprehensively, interventions enabled tailoring of information with two-way communication and active family involvement in decision-making processes.

CONCLUSIONS

Future research should use more robust methods and develop interventions with close inputs from families. We recommend using conceptual components of family engagement to ensure comprehensiveness of the intervention.

Defining effective communication for critically ill patients with an artificial airway: An international multi-professional consensus

OBJECTIVES

To define effective communication and identify its key elements specific to critically ill patients with an artificial airway.

DESIGN

A modified Consensus Development Panel methodology.

SETTING

International video-conferences.

MAIN OUTCOME MEASURES

Definition of effective communication and it's key elements.

RESULTS

Eight experts across four international regions and three professions agreed to form the Consensus Development Panel together with a Chair and one person with lived experience who reviewed the outputs prior to finalisation. "Communication for critically ill adult patients with an artificial airway (endotracheal or tracheostomy tube) is defined as the degree in which a patient can initiate, impart, receive, and understand information, and can range from an ineffective to effective exchange of basic to complex information between the patient and the communication partner(s). Effective communication encompasses seven key elements including: comprehension, quantity, rate, effort, duration, independence, and satisfaction. In critically ill adults, communication is impacted by factors including medical, physical and cognitive status, delirium, fatigue, emotional status, the communication partner and the nature of the ICU environment (e.g., staff wearing personal protective equipment, noisy equipment, bright lights)." The panel agreed that communication occurs on a continuum from ineffective to effective for basic and complex communication.

CONCLUSION

We developed a definition and list of key elements which constitute effective communication for critically ill patients with an artificial airway. These can be used as the basis of standard terminology to support future research on the development of communication-related outcome measurement tools in this population.

IMPLICATIONS FOR CLINICAL PRACTICE

This study provides international multi-professional consensus terminology and a definition of effective communication which can be used in clinical practice. This standard definition and key elements of effective communication can be included in our clinical impressions of patient communication, and be used in discussion with the patient themselves, their families and the multi-professional team, to guide care, goal development and intervention.

Patient and Caregiver-Derived Health Service Improvements for Better Critical Care Recovery

OBJECTIVES

To engage critical care end-users (survivors and caregivers) to describe their emotions and experiences across their recovery trajectory, and elicit their ideas and solutions for health service improvements to improve the ICU recovery experience.

DESIGN

End-user engagement as part of a qualitative design using the Framework Analysis method.

SETTING

The Society of Critical Care Medicine's THRIVE international collaborative sites (follow-up clinics and peer support groups).

SUBJECTS

Patients and caregivers following critical illness and identified through the collaboratives.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Eighty-six interviews were conducted. The following themes were identified: 1) Emotions and experiences of patients-"Loss of former self; Experiences of disability and adaptation"; 2) Emotions and experiences of caregivers-"Emotional impacts, adopting new roles, and caregiver burden; Influence of gender roles; Adaptation, adjustment, recalibration"; and 3) Patient and caregiver-generated solutions to improve recovery across the arc of care-"Family-targeted education; Expectation management; Rehabilitation for patients and caregivers; Peer support groups; Reconnecting with ICU post-discharge; Access to community-based supports post-discharge; Psychological support; Education of issues of ICU survivorship for health professionals; Support across recovery trajectory." Themes were mapped to a previously published recovery framework (Timing It Right) that captures patient and caregiver experiences and their support needs across the phases of care from the event/diagnosis to adaptation post-discharge home.

CONCLUSIONS

Patients and caregivers reported a range of emotions and experiences across the recovery trajectory from ICU to home. Through end-user engagement strategies many potential solutions were identified that could be implemented by health services and tested to support the delivery of higher-quality care for ICU survivors and their caregivers that extend from tertiary to primary care settings.

Patient and Family Participation in Medication Decisions on Discharge to Hospice Care

Background: High-quality hospice care is characterized by patient-centered care and shared decision making between patients, families, and health care workers. However, little is known regarding the frequency and characteristics of patient and family participation in medication decisions on transition to hospice care. Objective: To quantify the frequency and characteristics of patient and/or family participation in medication decisions. Subjects: Adult (age ≥18 years) patients discharged from Oregon Health & Science University Hospital (OHSU) to hospice care between January 1, 2010 and December 31, 2016. Design: Cross-sectional study. Measures: The primary outcome was documented patient and/or family participation. Patient or family participation was defined as documentation of patient or family member discussion surrounding medication decisions in the discharge summary. We used logistic regression to identify patient and admission characteristics associated with documentation of patient or family member participation in medication decisions. Results: Among 348 eligible patients, patient and/or family participation was documented in 22% of discharges to hospice care. Higher Charlson comorbidity index (adjusted odds ratio [aOR]: 1.09, 95% confidence interval [CI]: 1.01-1.17) and having a diagnosis of cancer (aOR: 1.99, 95% CI: 1.16-3.43) were associated with an increased documentation of patient or family member participation in medication decisions. Patients admitted to the intensive care unit were less likely to have patient/family member participation (aOR: 0.55, 95% CI: 0.32-0.94). Having a specialty palliative care consultation was not significantly associated with patient or family member participation in medication decisions (aOR: 0.77, 95% CI: 0.40-1.48). Conclusions: Patient or family participation in medication decisions was documented for only 22% patients on discharge to hospice care. Opportunities to improve participation likely include increasing knowledge and capacity regarding primary palliative care for all clinicians and implementation of specialized interventions for patients and families transitioning to hospice care from acute care settings.

Systematized and efficient: organization of critical care in the future

Since the advent of critical care in the twentieth century, the core elements that are the foundation for critical care systems, namely to care for critically ill and injured patients and to save lives, have evolved enormously. The past half-century has seen dramatic advancements in diagnostic, organ support, and treatment modalities in critical care, with further improvements now needed to achieve personalized critical care of the highest quality. For critical care to be even higher quality in the future, advancements in the following areas are key: the physical ICU space; the people that care for critically ill patients; the equipment and technologies; the information systems and data; and the research systems that impact critically ill patients and families. With acutely and critically ill patients and their families as the absolute focal point, advancements across these areas will hopefully transform care and outcomes over the coming years.

Assessment of Parent and Nurse Perceptions of Parental Participation in Hospital Paediatric Care

Background:

Parent and nurse perceptions about the care of hospitalized children have been examined in developed countries, but little is known in developing countries.

Objective:

The study aims to evaluate the perceptions of nurses and parents towards parental participation in care for hospitalized children and associated factors.

Methods:

A cross-sectional design was used to collect data from nurses and parents in paediatric units in the Eastern Region of Saudi Arabia using a convenience sampling technique. Data were collected using the Parent Participation Attitude Scale (PPAS), and the agreement and differences between groups were analysed.

Results:

The present results found that both parents and nurses agreed on 7 out of 20 statements regarding parental involvement in care for their children. Nurses in paediatric surgery had a higher perception of involving parents (P = 0.002), while nurses in Well Baby Nursery (WBN) ward had the lowest perception. The present findings confirm that married caregivers had higher perceptions (P = 0.035) than their single counterparts.

Conclusion:

Parent participation attitude was agreed on for seven statements between parents and nurses. More studies are required to explore the relationship between healthcare providers and parents with regard to parental participation in caring for hospitalized children.

Impact of Family Presence on Delirium in Critically Ill Patients: A Retrospective Cohort Study

OBJECTIVE

To assess the effect of family presence on the prevalence and duration of delirium in adults admitted to an ICU.

DESIGN

Retrospective cohort study.

SETTING

Medical-surgical ICUs in Alberta, AB, Canada.

PATIENTS

A population of 25,537 unique patients admitted at least once to an Alberta ICU.

METHODS

We obtained electronic health records of consecutive adults (≥ 18 yr) admitted to one of 14 medical-surgical ICU in Alberta, Canada, from January 1, 2014, to December 30, 2018. Family presence was quantified using a validated algorithm and categorized as: 1) physical presence in ICU, 2) telephone call only, and 3) no presence (reference group). Delirium was measured using the Intensive Care Delirium Screening Checklist (ICDSC) and defined as an ICDSC greater than or equal to 4. Multivariable mixed-effects logistic and linear regression were used to evaluate the association between family presence and prevalence (binary) and duration (d) of delirium, respectively.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The association between family presence and delirium prevalence differed according to admission type and admission Glasgow Coma Scale (GCS). Among medical and emergency surgical patients irrespective of admission GCS, physical presence of family was not significantly associated with the prevalence of delirium. In elective surgical patients, physical presence of family was associated with decreased prevalence of delirium in patients with intact Glasgow Coma Scale (GCS = 15; adjusted odds ratio, 0.60; 95% CI, 0.39-0.97; p = 0.02). Physical presence of family (adjusted mean difference [AMD] -1.87 d; 95% CI, -2.01 to -1.81; p < 0.001) and telephone calls (AMD -1.41 d; 95% CI, -1.52 to -1.31; p < 0.001) were associated with decreased duration of delirium in all patients.

CONCLUSIONS

The effects of family presence on delirium are complex and dependent on type of visitation, reason for ICU admission, and brain function on ICU admission.

Outcomes of family-centred auditory and tactile stimulation implementation on traumatic brain injured patients

AIM

To determine the outcomes of Family-centred Auditory and Tactile Stimulation Implementation on Traumatic Brain Injured Patients in Egypt.

BACKGROUND

Family engagement in the care of their relatives in the Intensive care units is limited due to patients' life-threatening conditions, in addition to the use of high technology in these settings. Auditory and tactile sensory stimulations are among the diverse sensory stimulations that have received more attention in brain injured patients than other senses as being considered safe, and effective measures.

DESIGN

A Quasi-experimental design was used to test the hypotheses of this study.

METHODS

A convenience sample of 60 adult patients suffering from Traumatic Brain Injury and admitted to the intensive care units of two University Hospitals in Egypt was included in the study. Patients were assigned into two equal groups: control and study groups (30 patients each). The auditory and tactile stimulations were provided by trained family members, once daily for 2 weeks for the study group. Whereas routine communication was provided by the family of traumatic brain injured patients in the ICU for the control group. Two tools were used for data collection; tool one, the "Glasgow Coma Scale" to assess patient's level of consciousness, and tool two the "Physiological Adverse Events Assessment" to monitor patients for the occurrence of physiological adverse events.

DATA COLLECTION

January to October 2019.

RESULTS

The implementation of an organized auditory and tactile stimulation by trained family members is associated with highly statistically significant positive effects . Patients in the study group showed a higher mean of consciousness, lower incidence rate of physiological adverse events, and a lower mean duration of ICU stay.

CONCLUSIONS

Implementation of an organized auditory and tactile stimulation by trained family members enhanced the consciousness level of comatose Traumatic Brain Injured patients, decreased the occurrence of physiological adverse events, and ICU length of stay. Thus, it is recommended for use in the daily routine nursing care of comatose Traumatic Brain Injured patients.

RELEVANCE TO CLINICAL PRACTICE

This study gives a deeper understanding of how family engagement in the care of their critically ill relative enhances their recovery and improve their level of consciousness.

Perspectives from designated family caregivers of critically ill adult patients during the COVID-19 pandemic: A qualitative interview study

Background

Family visitation in intensive care units (ICU) has been impacted by the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic. While studies report on perceptions of families completely restricted from ICUs, little is known about the burden experienced by designated family caregivers allowed to visit their critically ill loved one. This study sought the perspectives of family caregivers of critically ill patients on the impact of one-person designated visitor policies mandated in ICUs during the COVID-19 pandemic.

Methods

Throughout the study period a restricted visitation policy was mandated capturing the first (April 2020) and second (December 2020) waves of the pandemic that allowed one designated family caregiver (i.e., spouses or adult children) per patient to visit the ICU. Designated family caregivers of critically ill patients admitted to ICU September 2020 to November 2020 took part in individual 60-minute, semi-structured interviews at 6-months after discharge from the index ICU admission. Themes from family interviews were summarized with representative quotations.

Results

Key themes identified following thematic analysis from six participants included: one visitor rule, patient advocate role, information needs, emotional distress, strategies for coping with challenges, practicing empathy, and appreciation of growth.

Conclusion

Designated family caregivers of critically ill patients admitted to ICU during the COVID-19 pandemic perceived a complex and highly stressful experience. Support from ICU family liaisons and psychologists may help ameliorate the impact.

Patient and Family Representation in Randomized Clinical Trials Published in 3 Medical and Surgical Journals: A Systematic Review

IMPORTANCE

Patient and family engagement in research may improve the design, conduct, and dissemination of clinical research, but little is known about whether these stakeholder groups are involved in the design and conduct of randomized clinical trials.

OBJECTIVE

To characterize the involvement and role of patient and family representatives in the design and conduct of randomized clinical trials by reviewing randomized clinical trials from 3 peer-reviewed medical and surgical journals with high impact factors.

EVIDENCE REVIEW

In this systematic review, the first 50 consecutive randomized clinical trials published on or after January 1, 2021, until September 30, 2021, from each of 3 medical and surgical journals with high impact factors were reviewed for patient or family involvement in trial design and/or conduct. The manuscript, supplemental data, and trial registry records were searched for trial design and governance structures. Two independent, blinded reviewers screened citations and extracted data. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

FINDINGS

Only 7 of 150 randomized clinical trials (5%) reported patient or family representation in their study design or conduct. Most studies with patient or family representation (n = 5) were from a single journal. Stakeholder involvement was mainly in the execution phase (n = 7), although in 2 studies stakeholders were also involved in the translation phase.

CONCLUSIONS AND RELEVANCE

The findings of this systematic review suggest that patient or family involvement in the design and conduct of randomized clinical trials in the publications with high impact factors is lacking. We found that when patient or family groups are involved in research, the focus was mainly on the execution phase of research design. There is a need to increase stakeholder involvement in the research design, conduct, and translation of randomized clinical trials.

Including the voice of paediatric patients: Cocreation of an engagement game

Background

Engaging patients in health care, research and policy is essential to improving patient‐important health outcomes and the quality of care. Although the importance of patient engagement is increasingly acknowledged, clinicians and researchers still find it difficult to engage patients, especially paediatric patients. To facilitate the engagement of children and adolescents in health care, the aim of this project is to develop an engagement game.

Methods

A user‐centred design was used to develop a patient engagement game in three steps: (1) identification of important themes for adolescents regarding their illness, treatment and hospital care, (2) evaluation of the draft version of the game and (3) testing usability in clinical practice. Adolescents (12–18 years) were engaged in all steps of the development process through focus groups, interviews or a workshop. These were audio‐recorded, transcribed verbatim and analysed in MAXQDA.

Results

(1) The important themes for adolescents (N = 15) were included: visiting the hospital, participating, disease and treatment, social environment, feelings, dealing with staff, acceptation, autonomy, disclosure and chronically ill peers. (2) Then, based on these themes, the engagement game was developed and the draft version was evaluated by 13 adolescents. Based on their feedback, changes were made to the game (e.g., adjusting the images and changing the game rules). (3) Regarding usability, the pilot version was evaluated positively. The game helped adolescents to give their opinion. Based on the feedback of adolescents, some last adjustments (e.g., changing colours and adding a game board) were made, which led to the final version of the game, All Voices Count.

Conclusions

Working together with adolescents, All Voices Count, a patient engagement game was developed. This game provides clinicians with a tool that supports shared decision‐making to address adolescents' wishes and needs.

Patient or Public Contribution

Paediatric patients, clinicians, researchers, youth panel of Fonds NutsOhra and patient associations (Patient Alliance for Rare and Genetic Diseases, Dutch Childhood Cancer Organization) were involved in all phases of the development of the patient engagement game—from writing the project plan to the final version of the game.

Patient and public involvement in the build-up of COVID-19 testing in Sweden

Background

Patient and public involvement in healthcare can be particularly challenging during crises such as the COVID‐19 pandemic.

Objective

The aims of the study, which focuses on COVID‐19 testing in Sweden, were to explore (1) how, or to what extent, patients and members of the public were involved in decisions about the organization of COVID‐19 testing during the first year of pandemic and (2) whether this was seen as feasible or desirable by regional and national stakeholders.

Methods

A qualitative interview study was conducted with key organizational stakeholders at three national agencies and within three Swedish regions (n = 16).

Results

There had been no patient and public involvement activities in the area of COVID‐19 testing. The regions had, however, tried to respond to demands or critiques from patients and the public along the way and to adapt the services to respond to their preferences. The need for rapid decision‐making, the uncertainty about whom to involve, as well as a hesitation about the appropriateness of involving patients and the public contributed to the lack of involvement.

Conclusion

Future studies on patient and public involvement during crises should address what structures need to be in place to carry out involvement successfully during crises and when to use activities with varying degrees of power or decision‐making authority for patients and members of the public.

Patient or Public Contribution

Fifteen members of the public contributed with short reflections on the study findings.

Psychiatric Outcomes in ICU Patients With Family Visitation: A Population-Based Retrospective Cohort Study

BACKGROUND

Lack of family visitation in the ICU can have long-term consequences on patients in the ICU after discharge. The effect of family visitation on the incidence of patient psychiatric disorders is unknown.

RESEARCH QUESTION

What is the association between family visitation in the ICU and incidence of psychiatric outcomes in patients in the ICU 1 year after hospital discharge?

STUDY DESIGN AND METHODS

This study assessed a population-based retrospective cohort of adult patients admitted to the ICU from January 1, 2014, through May 30, 2017, surviving to hospital discharge with ICU length of stay of ≥ 3 days. To be eligible, patients needed to have minimum of 5 years of administrative data before ICU admission and a minimum of 1 year of follow-up data after hospital discharge. An internally validated algorithm that interpreted natural language in health records determined patients with or without in-person family (ie, relatives, friends) visitation during ICU stay. The primary outcome was risk of an incidence of psychiatric disorder (composite outcome), including anxiety, depressive, trauma- and stressor-related, psychotic, and substance use disorders, identified using coding algorithms for administrative databases. Propensity scores were used in inverse probability weighted logistic regression models, and average treatment effects were converted to risk ratios (RRs) with 95% CIs. Secondary outcomes were incidences of diagnoses by type of psychiatric disorder.

RESULTS

We included 14,344 patients with (96% [n = 13,771]) and without (4.0% [n = 573]) in-person family visitation who survived hospital discharge. More than one-third of patients received a diagnosis of any psychiatric disorder within 1 year after discharge (34.9%; 95% CI, 34.1%-35.6%). Patients most often received diagnoses of anxiety disorders (17.5%; 95% CI, 16.9%-18.1%) and depressive disorders (17.2%; 95% CI, 16.6%-17.9%). After inverse probability weighting of 13,731 patients, in-person family visitation was associated with a lower risk of received a diagnosis of any incident psychiatric disorder within 1 year after discharge (RR, 0.79; 95% CI, 0.68-0.92).

INTERPRETATION

ICU family visitation is associated with a decreased risk of psychiatric disorders in critically ill patients up to 1 year after hospital discharge.

Professionals' narratives of interactions with patients' families in intensive care

Background: ICU patients’ family members are in a new, uncertain, and vulnerable situation due to the patient’s critical illness and complete dependence on the ICU nurses and physicians. Family members’ feeling of being cared for is closely linked to clinicians’ attitudes and behavior.

Aim: To explore ICU nurses’ and physicians’ bedside interaction with critically ill ICU patients´ families and discuss this in light of the ethics of care.

Research design: A qualitative study using participant observation, focus groups, and thematic narrative analysis.

Participants and research context: Data were gathered from July 2017 to August 2019, in four ICUs in Norway through 270 h of fieldwork and seven focus groups with ICU nurses and physicians.

Ethical considerations: The Regional Committee for Medical and Health Research Ethics and the Norwegian Centre for Research Data approved the study. Findings: Quality of ICU family care depends on nurses’ and physicians’ attitudes, behavior, and personality traits. Three main themes were identified: being attentive, an active approach, and degree of tolerance.

Discussion: The findings are discussed in light of the ethics of care and empirical research from the intensive care environment.

Conclusions: This study shows that attentive, active, and tolerant clinicians represent a culture of ethical care that gives families greater freedom of action and active participation in patient care. Clinicians must not bear sole responsibility for this culture; it must have a firm basis in the hospital and ICU and be established through training, interprofessional reflection, and support of clinicians.

In-hospital interventions to promote relational practice with families in acute care settings: A scoping review

Relational practice is characterised by genuine interaction between families and healthcare professionals that promotes trust and empowerment. Positive clinical outcomes have been associated with relational practice. To assess and examine in-hospital interventions designed to promote relational practice with families in acute care settings of emergency departments, intensive care units and high care units. The preferred reporting Items for Systematic Reviews and Meta-Analyses guidelines informed the design of this scoping review. To identify relevant studies, databases (Academic Search Complete; CINAHL; PubMed; PsyInfo) and the search engine Google Scholar were searched using terms for core elements of relational practice and family engagement. Of the 117 articles retrieved, eight interventional studies met the search criteria. The interventions focused on relational practice elements of collaborating with and creating safe environments for families, whilst only one addressed healthcare professionals being respectful of families’ needs and differences. In relation to the nature of engagement of families in interventions, the focus was mainly on improving family functioning. Family engagement in the interventions was focused on involving families in decision-making. The scoping review revealed a limited number of in-hospital interventions designed to promote relational practice with families in acute care settings. Further research is encouraged to develop such interventions.

Patient and family engagement in patient care and research in Canadian intensive care units: a national survey

PURPOSE

While patient and family engagement may improve clinical care and research, current practices for engagement in Canadian intensive care units (ICUs) are unknown.

METHODS

We developed and administered a cross-sectional questionnaire to ICU leaders of current engagement practices, facilitators, and barriers to engagement, and whether engagement was a priority, using to an ordinal Likert scale from 1 to 10.

RESULTS

The response rate was 53.4% (124/232). Respondents were from 11 provinces and territories, mainly from medical surgical ICUs (76%) and community hospitals (70%). Engagement in patient care included bedside care (84%) and bedside rounds (66%), presence during procedures/crises (65%), and survey completion (77%). Research engagement included ethics committees (36%), protocol review (31%), and knowledge translation (30%). Facilitators of engagement in patient care included family meetings (87%), open visitation policies (81%), and engagement as an institutional priority (74%). Support from departmental (43%) and hospital (33%) leadership was facilitator of research engagement. Time was the main barrier to engagement in any capacity. Engagement was a higher priority in patient care vs research (median [interquartile range], 8 [7-9] vs 3 [1-7]; P < 0.001) and in pediatric vs adult ICUs (10 [9-10] vs 8 [7-9]; P = 0.003). Research engagement was significantly higher in academic vs other ICUs (7 [5-8] vs 2 [1-4]; P < 0.001), and pediatric vs adult ICUs (7 [5-8] vs 3 [1-6]; P = 0.01).

CONCLUSIONS

Organizational strategies and institutional support were key facilitators of engagement. Engagement in patient care was a higher priority than engagement in research.

Exploring the process of information sharing in an adult intensive care unit: an ethnographic study

Information sharing, a component of patient and family engagement (PFE), is an important process that may contribute to intensive care unit (ICU) quality of care. Yet, virtually no studies explore how the process of information sharing unfolds in the ICU from the interprofessional team and family member perspectives. To better understand the process of information sharing, we conducted ethnographic fieldwork in a 20-bed medical ICU, focusing on behaviors and interactions of the interprofessional team and family members (May 2016 - October 2016). We completed 17.5 observation hours, 6 shadowing sessions, and 12 semi-structured interviews with 17 total participants. We used thematic content analysis and iterative inductive coding to identify three themes about the information sharing process: 1) family factors (health literacy and past experience with the ICU environment) influence information sharing; 2) clinicians strategies can support engagement in the process of information sharing (assessing families' need for information, understanding a families' hope, using rounds as an opportunity for information sharing); 3) the process of information sharing allows for trust building between families and the ICU team. Our findings suggest that information sharing is a crucial process that may serve as a catalyst for effective patient and family engagement in the ICU.

Patient discharge from intensive care: an updated scoping review to identify tools and practices to inform high-quality care

BACKGROUND

Critically ill patients require complex care and experience unique needs during and after their stay in the intensive care unit (ICU). Discharging or transferring a patient from the ICU to a hospital ward or back to community care (under the care of a general practitioner) includes several elements that may shape patient outcomes and overall experiences. The aim of this study was to answer the question: what elements facilitate a successful, high-quality discharge from the ICU?

METHODS

This scoping review is an update to a review published in 2015. We searched MEDLINE, EMBASE, CINAHL, and Cochrane databases from 2013-December 3, 2020 including adult, pediatric, and neonatal populations without language restrictions. Data were abstracted using different phases of care framework models, themes, facilitators, and barriers to the ICU discharge process.

RESULTS

We included 314 articles from 11,461 unique citations. Two-hundred and fifty-eight (82.2%) articles were primary research articles, mostly cohort (118/314, 37.6%) or qualitative (51/314, 16.2%) studies. Common discharge themes across all articles included adverse events, readmission, and mortality after discharge (116/314, 36.9%) and patient and family needs and experiences during discharge (112/314, 35.7%). Common discharge facilitators were discharge education for patients and families (82, 26.1%), successful provider-provider communication (77/314, 24.5%), and organizational tools to facilitate discharge (50/314, 15.9%). Barriers to a successful discharge included patient demographic and clinical characteristics (89/314, 22.3%), healthcare provider workload (21/314, 6.7%), and the impact of current discharge practices on flow and performance (49/314, 15.6%). We identified 47 discharge tools that could be used or adapted to facilitate an ICU discharge.

CONCLUSIONS

Several factors contribute to a successful ICU discharge, with facilitators and barriers present at the patient and family, health care provider, and organizational level. Successful provider-patient and provider-provider communication, and educating and engaging patients and families about the discharge process were important factors in a successful ICU discharge.

Family Caregiver Preferences and Contributions Related to Patient Care in the ICU

Guided by Individual and Family Self-Management Theory, the purpose of this cross-sectional study was to describe patient care activities that family caregivers endorsed and performed while visiting their family member in the ICU. We found that caregivers wanted to be involved in ICU patient care and had preferences for the care they wanted to perform with their critically ill family member. More than 80% preferred to perform tasks related to daily grooming, communication, and education. Of note, many caregivers expressed interest in holistic healing activities (i.e., music and art), and yet, less than 50% of caregivers reported participating in these activities. The discrepancy between the number of care activities that respondents desired to perform compared to the number of care activities they reported performing represents an important opportunity to shift research and practice improvement efforts toward more tailored family engagement interventions and recognition of family caregivers as essential partners in care.

Initiating and integrating a personalized end of life care project in a community hospital intensive care unit: A qualitative study of clinician and implementation team perspectives

RATIONALE

The end of life (EOL) experience in the intensive care unit (ICU) can be psychologically distressing for patients, families, and clinicians. The 3 Wishes Project (3WP) personalizes the EOL experience by carrying out wishes for dying patients and their families. While the 3WP has been integrated in academic, tertiary care ICUs, implementing this project in a community ICU has yet to be described.

OBJECTIVES

To examine facilitators of, and barriers to, implementing the 3WP in a community ICU from the clinician and implementation team perspective.

METHODS

This qualitative descriptive study evaluated the implementation of the 3WP in a 20-bed community ICU in Southern Ontario, Canada. Patients were considered for the 3WP if they had a high likelihood of imminent death or planned withdrawal of life-sustaining therapy. Following the qualitative descriptive approach, semi-structured interviews were conducted with purposively sampled clinicians and implementation team. Data from transcribed interviews were analyzed in triplicate through qualitative content analysis.

RESULTS

Interviews with 12 participants indicated that the 3WP personalized and enriched the EOL experience. Interviewees indicated higher intensity education strategies were needed to enable spread as the project grew. Clinicians described many physical resources for the project but suggested more non-clinical project support for orientation, continuing education, and data collection. A majority of wishes focused on physical resources including keepsakes, which helped facilitate project spread when clinician capacity was attenuated by competing duties.

CONCLUSIONS

In this community hospital, ICU clinicians and implementation team members report perceived improved EOL care for patients, families, and clinicians following 3WP initiation and integration. Implementing individualized and meaningful wishes at EOL for dying patients in a community ICU requires adequate planning and time dedicated to optimizing clinician education. Adapting key features of an intervention to local expertise and capacity may facilitate spread during project initiation and integration.

Jordanian Patients' Family Members Need Perceptions in the Critical Care Settings: Nurses' Perspectives versus Family Members' Perspectives in the Context of Health Informatics

Background

An unexpected hospitalization in any of the Critical Care Units (CCUs) is a stressful condition, not only for patients but also for other family members. Research in this field in Jordan is not available. The main objective of this study was to identify the most important needs as perceived by these family members in the light of this stressful event and compare them with the nurses' perceptions of the importance of these needs and also to determine the perception of the needs' importance with the sociodemographic characteristics of both family members and caring nurses.

Methods

This was a cross-sectional study conducted in the period between February and August 2020 among adult family members of patients admitted to the CCUs in hospitals of Jordan from all sectors (public, private, and teaching). The "Critical Care Family Needs Inventory (CCFNI)" questionnaire was administered to 82 family members and 99 CCU nurses to determine the importance of the needs on the inventory. The data were analyzed using descriptive statistics.

Results

The most important need identified by the family members was relevant to the need for proximity (3.64 ± 0.45), followed by information (3.57 ± 0.58), assurance (3.44 ± 0.43), support (3.31 ± 0.62), and comfort (3.21 ± 0.56). Nurses identified the needs for assurance as the highest, followed by information, comfort, and support, whereas proximity was the least need perceived as very important. The top 10 important needs for both family members and nurses were identified. Family members and nurses were only common in 2 of the need statements on the scale. There was no significant association between the sociodemographic characteristics of the sample and the perception of the needs' importance (p=0.05).

Conclusion

This study has shown that nurses and family members of patients admitted to CCUs have different perspectives relevant to needs' importance. This should warn nurses to set the needs viewed by family members as a priority. Implications. In the CCU settings, in the context of advancing health informatics, families of patients in the ICUs have different needs other than those viewed by nurses. Their needs must be identified and considered.

Physical Restraint Use in Intensive Care Units: Exploring the Decision-Making Process and New Proposals. A Multimethod Study

Aim: The general aim of this study was to explore the decision-making process followed by Intensive Care Unit (ICU) health professionals with respect to physical restraint (PR) administration and management, along with the factors that influence it. Method: A qual-quant multimethod design was sequenced in two stages: an initial stage following a qualitative methodology; and second, quantitative with a predominant descriptive approach. The multicenter study was undertaken at 17 ICUs belonging to 11 public hospitals in the Madrid region (Spain) across the period 2015 through 2019. The qualitative stage was performed from an interpretative phenomenological perspective. A total of eight discussion groups (DG) were held, with the participation of 23 nurses, 12 patient care nursing assistants, and seven physicians. Intentional purposive sampling was carried out. DG were tape-recorded and transcribed. A thematic analysis of the latent content was performed. In the quantitative stage, we maintained a 96-h observation period at each ICU. Variables pertaining to general descriptive elements of each ICU, institutional pain-agitation/sedation-delirium (PAD) monitoring policies and elements linked to quality of PR use were recorded. A descriptive analysis was performed, and the relationship between the variables was analyzed. The level of significance was set at p ≤ 0.05. Findings: A total of 1070 patients were observed, amounting to a median prevalence of PR use of 19.11% (min: 0%–max: 44.44%). The differences observed between ICUs could be explained by a difference in restraint conceptualization. The various actors involved jointly build up a health care culture and a conceptualization of the terms “safety-risk”, which determine decision-making about the use of restraints at each ICU. These shared meanings are the germ of beliefs, values, and rituals which, in this case, determine the greater or lesser use of restraints. There were different profiles of PR use among the units studied: preventive restraints versus “Zero” restraints. The differences corresponded to aspects such as: systematic use of tools for assessment of PAD; interpretation of patient behavior; the decision-making process, the significance attributed to patient safety and restraints; and the feelings generated by PR use. The restraint–free model requires an approach to safety from a holistic perspective, with the involvement of all team members and the family.

The impact of patient delirium in the intensive care unit: patterns of anxiety symptoms in family caregivers

BACKGROUND

The purpose of this study was to examine the association of patient delirium in the intensive care unit (ICU) with patterns of anxiety symptoms in family caregivers when delirium was determined by clinical assessment and family-administered delirium detection.

METHODS

In this cross-sectional study, consecutive adult patients anticipated to remain in the ICU for longer than 24 h were eligible for participation given at least one present family caregiver (e.g., spouse, friend) provided informed consent (to be enrolled as a dyad) and were eligible for delirium detection (i.e., Richmond Agitation-Sedation Scale score ≥ - 3). Generalized Anxiety Disorder-7 (GAD-7) was used to assess self-reported symptoms of anxiety. Clinical assessment (Confusion Assessment Method for ICU, CAM-ICU) and family-administered delirium detection (Sour Seven) were completed once daily for up to five days.

RESULTS

We included 147 family caregivers; the mean age was 54.3 years (standard deviation [SD] 14.3 years) and 74% (n = 129) were female. Fifty (34% [95% confidence interval [CI] 26.4-42.2]) caregivers experienced clinically significant symptoms of anxiety (median GAD-7 score 16.0 [interquartile range 6]). The most prevalent symptoms of anxiety were "Feeling nervous, anxious or on edge" (96.0% [95%CI 85.2-99.0]); "Not being able to stop or control worrying" (88.0% [95%CI 75.6-94.5]; "Worrying too much about different things" and "Feeling afraid as if something awful might happen" (84.0% [95%CI 71.0-91.8], for both). Family caregivers of critically ill adults with delirium were significantly more likely to report "Worrying too much about different things" more than half of the time (CAM-ICU, Odds Ratio [OR] 2.27 [95%CI 1.04-4.91]; Sour Seven, OR 2.28 [95%CI 1.00-5.23]).

CONCLUSIONS

Family caregivers of critically ill adults with delirium frequently experience clinically significant anxiety and are significantly more likely to report frequently worrying too much about different things. Future work is needed to develop mental health interventions for the diversity of anxiety symptoms experienced by family members of critically ill patients.

TRIAL REGISTRATION

This study is registered on ClinicalTrials.gov ( https://clinicaltrials.gov/ct2/show/NCT03379129 ).

Defining and Redefining Family Involvement in Practice: An Implementation Trial of a Locally Adaptable Patient-Centered Professional Development Tool in Two Ontario Intensive Care Units

Research on best practices for family member involvement has shown that such involvement improves care quality in critical care settings and helps to reduce medical errors leading to adverse events. Although many critical care units promote the principle of "patient-centered care" and family member involvement, there can be a significant gap between knowledge about these processes and their translation into practice. This article is based on an implementation trial of a patient and family involvement knowledge-based tool that involves an educational component for frontline health care workers. By combining ethnographic observation, semistructured interviews, focus groups, and document analysis, we were able to not only examine health care provider views on family involvement but also explore the areas of tension that arose in practice because the introduction of the family involvement tool exposed local factors that shaped the conditions of possibility of family involvement. In particular, unspoken preferences, assumptions, and concerns about family involvement were brought to the fore because this intervention disrupted well-entrenched power dynamics related to family involvement and professional boundaries. Through this ethnographic research, we found that the concept of patient-centered care is not uncontroversial among health care providers and that the form of its practice was largely up for individual interpretation. Interventions and policies that aim to promote patient-centered and family-centered care would benefit from addressing the ways in which these ideas affect the work of different health care professionals and incorporating nursing concerns around family involvement.

Restricted visitation policies in acute care settings during the COVID-19 pandemic: a scoping review

Background

Restricted visitation policies in acute care settings because of the COVID-19 pandemic have negative consequences. The objective of this scoping review is to identify impacts of restricted visitation policies in acute care settings, and describe perspectives and mitigation approaches among patients, families, and healthcare professionals.

Methods

We searched Medline, Embase, PsycINFO, Healthstar, CINAHL, Cochrane Central Register of Controlled Trials on January 01/2021, unrestricted, for published primary research records reporting any study design. We included secondary (e.g., reviews) and non-research records (e.g., commentaries), and performed manual searches in web-based resources. We excluded records that did not report primary data. Two reviewers independently abstracted data in duplicate.

Results

Of 7810 citations, we included 155 records. Sixty-six records (43%) were primary research; 29 (44%) case reports or case series, and 26 (39%) cohort studies; 21 (14%) were literature reviews and 8 (5%) were expert recommendations; 54 (35%) were commentary, editorial, or opinion pieces. Restricted visitation policies impacted coping and daily function (n = 31, 20%) and mental health outcomes (n = 29, 19%) of patients, families, and healthcare professionals. Participants described a need for coping and support (n = 107, 69%), connection and communication (n = 107, 69%), and awareness of state of well-being (n = 101, 65%). Eighty-seven approaches to mitigate impact of restricted visitation were identified, targeting families (n = 61, 70%), patients (n = 51, 59%), and healthcare professionals (n = 40, 46%).

Conclusions

Patients, families, and healthcare professionals were impacted by restricted visitation polices in acute care settings during COVID-19. The consequences of this approach on patients and families are understudied and warrant evaluation of approaches to mitigate their impact. Future pandemic policy development should include the perspectives of patients, families, and healthcare professionals.

Trial registration: The review was registered on PROSPERO (CRD42020221662) and a protocol peer-reviewed prior to data extraction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03763-7.

The core of patient-participation in the Intensive Care Unit: The patient's views

OBJECTIVES

Patient participation is an established concept in public welfare. However, reports of the phenomenon of patient participation during intensive care from the patient's point of view are scarce. Therefore, the aim of this study was to explore the meaning of patient participation in the intensive care unit from the patient's perspective.

RESEARCH DESIGN

A qualitative design was used for the purpose of the study with a purposive convenient sample of nine adult patients with memories from their intensive care stay.

METHOD

Data was collected through individual interviews and analysed using a phenomenological hermeneutical method.

FINDINGS

The results of our study show a variety of meanings and degrees of participation that continuously move on a sliding scale from acting as a captain to feelings of being on an isolated island. Patient participation varied due to individual cognitive abilities and individual preferences, and the caregiver's attention altered between the body and the person through the continuum of care.

CONCLUSION

Patient participation during ICU care is more than participation in decision-making processes or direct patient care decisions. An understanding of the concept participation from the individual patient is necessary to support person centred care and the patient's relatives play an important role in during the entire care process.

Managerial and organisational prerequisites for the integration of palliative care in the intensive care setting: A qualitative study

AIM

To explore the association of organizational structures when integrating palliative care in intensive care units.

BACKGROUND

Palliative care within intensive care settings has been widely recognized as an area requiring improvement when caring for patients and their families. Despite this, intensive care units continue to struggle to integrate palliative care.

METHODS

A qualitative descriptive methodology was used. Data were collected through research interviews with 15 managers and 36 health care professionals working in intensive care. The data were analysed adopting constant comparative analysis.

RESULTS

This study provides insight into a diverse range of perspectives on organizational structure in the context of facilitation and the challenges posed. Three themes were identified: Do not resuscitate policy as a gateway to palliative care, facilitating family members to enable participation and support and barriers for palliative care in intensive care unit as a result of intensive care organization.

CONCLUSIONS

In fostering a sustainable organizational culture and practice development in intensive care, the findings indicate the need for specific palliative care policies and implementation strategies tailored according to context.

IMPLICATIONS FOR NURSING MANAGEMENT

Management has a responsibility to facilitate dialogue within any multidisciplinary team regarding palliative care and, in particular, to focus on 'do not resuscitate' policies as a gateway into this conversation.

Written Care Summaries Facilitate Communication Between Families and Providers of ICU Patients: A Pilot Study

Supplemental Digital Content is available in the text.

OBJECTIVES:

ICU providers may invite families to participate in daily rounds to inform them of the patient’s condition and to support their emotional well-being. Daily written summaries of care may provide complementary benefits.

DESIGN:

Qualitative interviews with surrogates of ICU patients who received daily written summaries of care.

SETTING:

Single, urban academic medical center.

PATIENTS/SUBJECTS:

A convenience sample of 30 surrogates of nondecisional, medical ICU patients.

INTERVENTIONS:

Daily written summaries detailed each of the patient’s main ICU problems, the presumed causes of each of the problems, and the medical team’s plan to address each of the problems for each ICU day.

MEASUREMENTS AND MAIN RESULTS:

There were four ways that written summaries affected the participant’s experience: 1) providing clarity to participants regarding the patient’s condition, 2) facilitating participant understanding of the patient’s clinical course, 3) facilitating communication between participants and medical providers, and 4) facilitating communication between participants and other family members. Overarching themes were that summaries were understandable, had appropriate level of detail, and added value to the ICU experience.

CONCLUSIONS:

In this pilot study, family members had positive impressions of receiving daily written summaries of care. Further study is needed to determine the extent to which written communication may affect family and patient outcomes.

Delirium-related distress in the ICU: A qualitative meta-synthesis of patient and family perspectives and experiences

BACKGROUND

Better understanding of patient and family member experiences of delirium and related distress during critical care is required to inform the development of targeted nonpharmacologic interventions.

OBJECTIVE

To examine and synthesize qualitative data on patient and family member delirium experiences and relieving factors in the Intensive Care Unit (ICU).

DESIGN

We conducted a systematic review and qualitative meta-synthesis. Eligible studies contained adult patient or family quotes about delirium during critical care, published in English in a peer-reviewed journal since 1980. Data sources included PubMed, Embase, CINAHL, PsycINFO, Web of Science, Cochrane and Clinicaltrials.gov.

METHODS

Systematic searches yielded 3238 identified articles, of which 14 reporting 13 studies were included. Two reviewers independently extracted data into a Microsoft Excel spreadsheet. Qualitative meta-synthesis was performed through line-by-line coding of relevant quotes, organization of codes into descriptive themes, and development of analytical themes. Five patients/family members with experience of ICU delirium contributed to the thematic analysis.

RESULTS

Qualitative meta-synthesis resulted in four major themes and two sub-themes. Key new patient and family-centric insights regarding delirium-related distress in the ICU included articulation of the distinct emotions experienced during and after delirium (for patients, predominantly fear, anger and shame); its 'whole-person' nature; and the value that patients and family members placed on clinicians' compassion, communication, and connectedness.

CONCLUSIONS

Distinct difficult emotions and other forms of distress are experienced by patients and families during ICU delirium, during which patients and families highly value human kindness and empathy. Future studies should further explore and address the many facets of delirium-related distress during critical care using these insights and include patient-reported measures of the predominant difficult emotions.

Editors-in-chief perceptions of patients as (co) authors on publications and the acceptability of ICMJE authorship criteria: a cross-sectional survey

BACKGROUND

Access to, and awareness of, appropriate authorship criteria is an important right for patient partners. Our objective was to measure medical journal Editors-in-Chief' perceptions of including patients as (co-)authors on research publications and to measure their views on the application of the ICMJE (International Committee of Medical Journals Editors) authorship criteria to patient partners.

METHODS

We conducted a cross-sectional survey co-developed with a patient partner. Editors-in-Chief of English-language medical journals were identified via a random sample of journals obtained from the Scopus source list. The key outcome measures were whether Editors-in-Chief believed: 1) patient partners should be (co-)authors and; 2) whether they felt the ICMJE criteria for authorship required modification for use with patient partners. We also measured Editors-in-Chief description of how their journal's operations incorporate patient partner perspectives.

RESULTS

One hundred twelve Editors-in-Chief responded to our survey (18.7% response rate; 66.69% male). Participants were able to skip any questions they did not want to answer, so there is missing data for some items. 69.2% (N = 74) of Editors-in-Chief indicated it was acceptable for patient partners to be authors or co-authors on published biomedical research articles, with the remaining 30.8% (N = 33) indicating this would not be appropriate. When asked specifically about the ICMJE authorship criteria, and whether this should be revised to be more inclusive of patient partners, 35.8% (N = 39) indicated it should be revised, 35.8% (N = 39) indicated it should not be revised, and 28.4% (N = 31) were unsure about a revision. 74.1% (N = 80) of Editors-in-Chief did not think patients should be required to have an academic affiliation to published while 16.7% (N = 18) and 9.3% (N = 10) indicated they should or were unsure. 3.6% (N = 4) of Editors-in-Chief indicated their journal had a policy that specifies how patients or patient partners should be considered as authors.

CONCLUSIONS

Our findings highlight gaps that may act as barriers to patient partner participation in research. A key implication is the need for education and for consensus building within the biomedical community to establish processes that will facilitate equitable patient partners inclusion.

Intensive care nurse-family engagement from a global perspective: A qualitative multi-site exploration

BACKGROUND

Critical illness is distressing for families, and often results in negative effects on family health that influence a family's ability to support their critically ill family member. Although recent attention has been directed at improving care and outcomes for families of critically ill patients, the manner in which nurses engage with families is not fully understood.

OBJECTIVES

To describe nurses' perceptions and practices of family engagement in adult intensive care units from a global perspective.

DESIGN

A qualitative-descriptive multi-site design using content analysis.

SETTINGS

The study was conducted in 26 intensive care units of 12 urban, metropolitan, academic medical centers in ten countries, spanning five continents.

PARTICIPANTS

A total of 65 registered nurses (77% women, age of M = 39.5, SD = 11.4 years) participated. Most held intensive care certification (72%) and had worked on average 10 (SD = 9.6) years in the ICU.

METHODS

Semi-structured, individual interviews (M = 38.4 min, SD = 12.0) were held with ICU nurses at the hospital (94%) or their home using an interview guide. Qualitative interview data were analysed using inductive content analysis.

RESULTS

We found that nurse-family engagement was an ebb and flow of relational power that needed to be carefully negotiated and balanced, with nurses holding and often exerting more power than families. Constant fluctuations in nurses' practices of engagement occurred in day-to-day practice from shift-to-shift and from nurse-to-nurse. Family engagement was dependent on individual nurses' attitudes and perceptions of family, the patient's condition, and workload. Lastly, family engagement was shaped by the ICU context, with team culture, collaborative relationships, unit structures and organizational resources either enabling or limiting nurses' ability to engage with families.

CONCLUSIONS

This global study provides an in-depth understanding of the way nurses engage with families in ICU and reflects many different cultures and health systems. We found that nurse-family engagement was marked by a shifting, yet often unequal power distribution in the nurse-family relationship, inconsistent nurse engagement practices, both of which resulted in variable family engagement in intensive care. Our research contributes a detailed description of engagement as practiced in the everyday delivery of health care. A more concentrated team effort, based on a shared culture and defined framework of family care is needed to ensure that families of critically ill persons are fully engaged in all aspects of intensive care.

Partnering With Family Members to Detect Delirium in Critically Ill Patients

OBJECTIVES

To evaluate the diagnostic accuracy of family-administered tools to detect delirium in critically ill patients.

DESIGN

Diagnostic accuracy study.

SETTING

Large, tertiary care academic hospital in a single-payer health system.

PATIENTS

Consecutive, eligible patients with at least one family member present (dyads) and a Richmond Agitation-Sedation Scale greater than or equal to -3, no primary direct brain injury, the ability to provide informed consent (both patient and family member), the ability to communicate with research staff, and anticipated to remain admitted in the ICU for at least a further 24 hours to complete all assessments at least once.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Family-administered delirium assessments (Family Confusion Assessment Method and Sour Seven) were completed once daily. A board-certified neuropsychiatrist and team of ICU research nurses conducted the reference standard assessments of delirium (based on Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition, criteria) once daily for a maximum of 5 days. The mean age of the 147 included patients was 56.1 years (SD, 16.2 yr), 61% of whom were male. Family members (n = 147) were most commonly spouses (n = 71, 48.3%) of patients. The area under the receiver operating characteristic curve on the Family Confusion Assessment Method was 65.0% (95% CI, 60.0-70.0%), 71.0% (95% CI, 66.0-76.0%) for possible delirium (cutpoint of 4) on the Sour Seven and 67.0% (95% CI, 62.0-72.0%) for delirium (cutpoint of 9) on the Sour Seven. These area under the receiver operating characteristic curves were lower than the Intensive Care Delirium Screening Checklist (standard of care) and Confusion Assessment Method for ICU. Combining the Family Confusion Assessment Method or Sour Seven with the Intensive Care Delirium Screening Checklist or Confusion Assessment Method for ICU resulted in area under the receiver operating characteristic curves that were not significantly better, or worse for some combinations, than the Intensive Care Delirium Screening Checklist or Confusion Assessment Method for ICU alone. Adding the Family Confusion Assessment Method and Sour Seven to the Intensive Care Delirium Screening Checklist and Confusion Assessment Method for ICU improved sensitivity at the expense of specificity.

CONCLUSIONS

Family-administered delirium detection is feasible and has fair, but lower diagnostic accuracy than clinical assessments using the Intensive Care Delirium Screening Checklist and Confusion Assessment Method for ICU. Family proxy assessments are essential for determining baseline cognitive function. Engaging and empowering families of critically ill patients warrant further study.

Intensive Care Unit Nurse: Could We Call a Palliative Care Consult? Intensive Care Unit Provider: It's Too Early. Palliative Care Integration in the Intensive Care Unit: The Struggle to Translate Evidence Into Practice

Despite evidence regarding the value of palliative care, there remains a translation-to-practice gap in the intensive care setting. The purpose of this article is to describe challenges and propose solutions to palliative care integration through the presentation and discussion of a critical care patient scenario. We also present recommendations for a collaborative palliative care practice framework that holds the potential to improve quality of life for patients and families. Collaborative palliative care is characterized by close working relationships with families, interprofessional intensive care unit healthcare teams, and palliative care specialists. The shortage of palliative care specialists has become a pressing policy and practice issue and highlights the importance of increasing primary palliative care delivery by the intensive care team. Underexplored aspects of collaborative palliative care delivery include the interprofessional communication required, identification of key skills, and expected outcomes. Increased recognition of intensive care unit palliative care as a process of engagement among nurses, providers, patients, and their family members heralds a vital culture shift toward collaborative palliative care. The interprofessional palliative specialist team has the expertise to support intensive care teams in developing their primary palliative skills and recognizing when specialist palliative care support is required. Promotion of strategic palliative care delivery through this collaborative framework has the potential to decrease suffering among patients and families and reduce moral distress among healthcare professionals.

Associations between caregiver-detected delirium and symptoms of depression and anxiety in family caregivers of critically ill patients: a cross-sectional study

BACKGROUND

Witnessing delirium can be distressing for family caregivers (i.e., relatives or friends) of critically ill patients. This study aimed to evaluate associations between caregiver-detected delirium in critically ill patients and depression and anxiety symptoms in their family caregivers.

METHODS

Consecutive adult patient-caregiver dyads were enrolled from a 28-bed medical-surgical intensive care unit. Patient delirium was screened for daily by family caregivers using the Sour Seven instrument. Family caregivers completed the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) instruments daily to assess their own depression and anxiety symptoms. Response feature analysis was used to handle repeated measures. Descriptive statistics and regression analyses were completed.

RESULTS

One hundred forty-seven patient-caregiver dyads were enrolled. Clinically significant symptoms of depression and anxiety occurred in 27% and 35% of family caregivers, respectively. Caregiver-detected delirium occurred in 65% of patients, and was not associated with clinically significant caregiver depression (Odds Ratio [OR] 1.4, 95% Confidence Interval [95%CI] 0.6-3.1) or anxiety (OR 1.2, 95%CI 0.6-2.6) symptoms. When stratified by Sour Seven scores, scores 1-3 and 4-9 were associated with increased symptoms of anxiety (OR 3.1, 95%CI 1.3-7.0) and depression (OR 2.6, 95%CI 1.1-6.1) in family caregivers. Caregiver-detected delirium score was associated with severity of family caregiver anxiety symptoms (coefficient 0.2, 95%CI 0.1-0.4), but not depression symptoms (coefficient 0.2, 95%CI -0.0-0.3).

CONCLUSIONS

Caregiver-detected patient delirium was associated with increased depression and anxiety symptoms in family caregivers of critically ill patients. Further randomized research is required to confirm these associations.

The Initial Impact of the Coronavirus Disease 2019 Pandemic on ICU Family Engagement: Lessons Learned From a Collaborative of 27 ICUs

Supplemental Digital Content is available in the text.

Objectives:

To describe the impact of coronavirus disease 2019 on family engagement among ICUs participating in a multicenter collaborative promoting implementation of family-centered care projects and to report sites’ experiences with the collaborative itself prior to its cancelation due to the pandemic in March 2020.

Design:

Cross-sectional survey.

Setting:

Twenty-seven academic and community ICUs in the United States and South Korea.

Subjects:

Site leaders.

Interventions:

Prior to March 2020, all sites had participated in 6 months of webinars, monthly calls, and listserv communication to facilitate projects and to collect preimplementation family satisfaction and clinician perception data.

Measurements and Main Results:

Planned projects included ICU orientation initiatives (12, 44.4%), structured family care conferences (6, 22.2%), and ICU diaries (5, 18.5%). After cancelation of the collaborative, 22 site leaders (81.5%) were surveyed by phone from June 2020 to July 2020. Twenty (90.1%) reported having stopped their site project; projects that continued were 1) a standardized palliative extubation protocol and 2) daily written clinical summaries for families. Sites described significant variability in visitor restriction policies and uncertainty regarding future policy changes. Four sites (18.2%) reported that their hospital did not provide personal protective equipment to visitors. Regarding video conferencing with families, 11 sites (52.4%) reported clinicians’ using their own personal devices. Two-hundred twelve family surveys and 346 clinician surveys collected prior to cancelation highlighted a broad need for family support. When leaders were asked on a scale from 0 to 10 how helpful collaborative activities had been prior to cancelation, mean response was 8.0 (sd 2.5).

Conclusions:

While the collaborative model can help promote ICU family engagement initiatives, coronavirus disease 2019 has impeded implementation of these initiatives even among motivated units. ICUs need adequate personal protective equipment for visitors and video conferencing capabilities on hospital devices while strict visitor restrictions continue to evolve.

Improving racial disparities in unmet palliative care needs among intensive care unit family members with a needs-targeted app intervention: The ICUconnect randomized clinical trial

INTRODUCTION

The technologies used to treat the millions who receive care in intensive care unit (ICUs) each year have steadily advanced. However, the quality of ICU-based communication has remained suboptimal, particularly concerning for Black patients and their family members. Therefore we developed a mobile app intervention for ICU clinicians and family members called ICUconnect that assists with delivering need-based care.

OBJECTIVE

To describe the methods and early experiences of a clustered randomized clinical trial (RCT) being conducted to compare ICUconnect vs. usual care.

METHODS AND ANALYSIS

The goal of this two-arm, parallel group clustered RCT is to determine the clinical impact of the ICUconnect intervention in improving outcomes overall and for each racial subgroup on reducing racial disparities in core palliative care outcomes over a 3-month follow up period. ICU attending physicians are randomized to either ICUconnect or usual care, with outcomes obtained from family members of ICU patients. The primary outcome is change in unmet palliative care needs measured by the NEST instrument between baseline and 3 days post-randomization. Secondary outcomes include goal concordance of care and interpersonal processes of care at 3 days post-randomization; length of stay; as well as symptoms of depression, anxiety, and post-traumatic stress disorder at 3 months post-randomization. We will use hierarchical linear models to compare outcomes between the ICUconnect and usual care arms within all participants and assess for differential intervention effects in Blacks and Whites by adding a patient-race interaction term. We hypothesize that both compared to usual care as well as among Blacks compared to Whites, ICUconnect will reduce unmet palliative care needs, psychological distress and healthcare resource utilization while improving goal concordance and interpersonal processes of care. In this manuscript, we also describe steps taken to adapt the ICUconnect intervention to the COVID-19 pandemic healthcare setting.

ENROLLMENT STATUS

A total of 36 (90%) of 40 ICU physicians have been randomized and 83 (52%) of 160 patient-family dyads have been enrolled to date. Enrollment will continue until the end of 2021.