Effectiveness Trial of an Intensive Communication Structure for Families of Long-Stay ICU Patients

doi:10.1378/chest.10-0292

Chest

Volume 138, Issue 6, December 2010, Pages 1340-1348

https://doi.org/10.1378/chest.10-0292 Get rights and content

Background

Formal family meetings have been recommended as a useful approach to assist in goal setting, facilitate decision making, and reduce use of ineffective resources in the ICU. We examined patient outcomes before and after implementation of an intensive communication system (ICS) to test the effect of regular, structured formal family meetings on patient outcomes among long-stay ICU patients.

Methods

One hundred thirty-five patients receiving usual care and communication were enrolled as the control group, followed by enrollment of intervention patients (n = 346), from five ICUs. The ICS included a family meeting within 5 days of ICU admission and weekly thereafter. Each meeting discussed medical update, values and preferences, and goals of care; treatment plan; and milestones for judging effectiveness of treatment.

Results

Using multivariate analysis, there were no significant differences between control and intervention patients in length of stay (LOS), the primary end point. Similarly, there were no significant differences in indicators of aggressiveness of care or treatment limitation decisions (ICU mortality, LOS, duration of ventilation, treatment limitation orders, or use of tracheostomy or percutaneous gastrostomy). Exploratory analysis suggested that in the medical ICUs, the intervention was associated with a lower prevalence of tracheostomy among patients who died or had do-not-attempt-resuscitation orders in place.

Conclusions

The negative findings of the main analysis, in combination with preliminary evidence of differences among types of unit, suggest that further examination of the influence of patient, family, and unit characteristics on the effects of a system of regular family meetings may be warranted. Despite the lack of influence on patient outcomes, structured family meetings may be an effective approach to meeting information and support needs.

Trial registry

ClinicalTrials.gov; No.: NCT01057238; URL: www.clinicaltrials.gov

Section snippets

Materials and Methods

A pre-post (before-after) design was used, and all patients meeting the eligibility criteria were enrolled consecutively. The control group (usual care) consisted of 135 patients and corresponding families enrolled from November 2005 to April 2006. We then implemented the intervention from May 2006 through February 2008, and enrolled 354 patients and family members. Institutional review board approvals from the two hospitals were obtained prior to study initiation.

Results

Figure 1 displays the sample enrollment, refusals, and dropouts, and Table 1 compares the experimental and control group on key clinical and demographic variables for patients as well as caregivers. There were significant differences between control and intervention groups (Table 1) on univariate analysis. Patients in the control group were older, more likely to have received care in the neuroscience ICU, less likely to have had treatment limitations in addition to a

Discussion

There is widespread agreement about the importance of skilled and sensitive communication with families of critically ill patients. Previous studies have focused on specific communicative techniques, such as active listening, use of emotionally supportive statements, and facilitation of shared decision making.26, 27, 28 The hypothesized mechanism of our intervention was that early and consistent communication that included explicit discussion of patient preferences, values, and goals would

Conclusions

The lack of the hypothesized effect of the intervention on the sample as a whole is strong evidence that the dynamics of decision making surrounding goals of care and aggressiveness of intervention are sufficiently complex that no single communication intervention is likely to have equivalent effects with all family members, in all environments. Directions for future research suggested by our findings include testing approaches that are tailored to family decision-making preferences and further

Acknowledgments

Author contributions: Dr Daly had full access to all data in the study and takes full responsibility for the integrity of all data and the accuracy of the data analysis.

Dr Daly: contributed to conceptualization of the project, all aspects of the conduct of the research, manuscript preparation, and approval of the final manuscript.

Dr Douglas: contributed to conceptualization of the project, all aspects of the conduct of the research, statistical analysis, manuscript preparation, and approval of

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Cited by (89)

The future of training in intensive care medicine: A European perspective
2023, Journal of Intensive Medicine
Communication and Palliation in Trauma Critical Care: Impact of Trainee Education and Mentorship
2021, Journal of Surgical Research
Surgical residency training requires Advance Care Planning (ACP) and Palliative Care (PC) education. To meet education needs and align with American College of Surgeons guidelines, our Surgical Intensivists and PC faculty developed courses on communication and palliation for residents (2017-18) and fellows (2018-19). We hypothesized that education in ACP would increase ACP communication and documentation.
The trauma registry of an academic, level 1trauma center was queried for ICU admissions from 2016-2019, excluding incarcerated and pregnant patients. A retrospective chart review was performed, obtaining frequency of ACP documentation, ACP meetings, time from admission to documentation, and PC consultation. We collected ICU quality measures as secondary outcomes: ICU Length Of Stay (LOS), hospital LOS, ventilator days, invasive procedures, discharge disposition, and mortality. Comparisons were made between years prior to (Y 1) and following implementation (Y 2: residents, Y 3: fellows).
For 1732 patients meeting inclusion criteria, patient demographics, injuries, and injury severity score were comparable. ACP documentation increased from 19.5% in Y 1 to 57.2% in Y 3 (P < 0.001). Time to ACP documentation was reduced from 47.6 to 13.1 h (P < 0.001) from time of admission. ICU LOS decreased from 6 to 4.8 d (P = 0.004). Patients in Y 3 had fewer tracheostomies and percutaneous endoscopic gastrostomies. PC consultations decreased. Mortality was unchanged.
Following trainee education, we observed increases in ACP documentation, earlier communication and improvements in ICU quality measures. Our findings suggest that trainee education positively impacts ACP documentation, reduces LOS, and improves trauma critical care outcomes.
Perspectives of intensive care nurses on open visits in an ICU
2021, Enfermeria Intensiva
Conocer la opinión de los profesionales de enfermería de una Unidad de Cuidados Intensivos Polivalente (UCI) respecto a los efectos de la visita abierta en el paciente, en la familia y en la actividad diaria de los profesionales, así como sus aportaciones a la actual política de visitas abiertas.
Estudio transversal, descriptivo, mediante muestreo discrecional no probabilístico. La muestra estuvo formada por profesionales de enfermería de la citada Unidad. Se les entregó un cuestionario con 26 ítems, desarrollado y adaptado por Marco et al., además de una pregunta abierta.
La tasa de participación fue del 84% de los profesionales de la unidad (101/120). El 75,2% manifestó que el equipo de enfermería tiene que posponer o modificar su trabajo debido a la presencia de la familia y el 89,9% que su presencia produce una carga física y psíquica al personal. El 80% pensaba que la visita agota a la familia y el 84,2% que la familia se siente obligada a permanecer con el paciente. El 94% opinó que el efecto de la presencia de la familia depende del paciente y de la familia.
La mayoría de los profesionales han tenido una opinión negativa hacia la política de visitas abiertas, mostrando cierta reticencia a la hora de flexibilizar los horarios de visita; aunque admitieron que un horario sin restricciones en este tipo de unidades supone cierto grado de beneficio para el paciente y la familia.
To determine the attitude of the nursing professionals of an Intensive Care Unit regarding the effects of open visiting on the daily activities of the patient, their family and professionals, and also to determine their contribution to the current open visiting policy.
A cross-sectional descriptive study was performed, with a non-probabilistic discretionary sampling. The sample comprised nursing professionals of the aforementioned Unit. They were given a questionnaire with 26 items and an open question to evaluate their suggestions.
101 nursing professionals took part in the study, of the 120 working in the Unit under study. Seventy-five point two percent state that the nursing team has to postpone or modify their work due to the presence of the family and 89.9% that their presence produces a physical and psychological burden on the staff. Eighty percent think that the visit exhausts the family and 84.2% that the family feels obliged to remain with the patient. Ninety-four percent think that the effect of the presence of the family depends on the patient and the family.
Most of professionals have a negative opinion about the policy of open visits, showing some reluctance when it comes to flexible visiting hours, although they admit that an unrestricted schedule in this type of units implies some benefit for the patient and the family.
The process of giving information to families in intensive care units: A narrative review
2021, Enfermeria Intensiva
La información es una de las necesidades más importantes de los familiares de pacientes críticos. Los profesionales sanitarios identifican también el gran valor de la comunicación con los familiares para reducir su ansiedad y su estrés. A pesar de ello, los familiares pueden sentirse indebidamente informados, lo cual causa un sufrimiento añadido. El objetivo de este estudio es tratar de comprender las perspectivas de los familiares y los profesionales sanitarios sobre la información que se aporta en las unidades de cuidados intensivos (UCI).
Se realizó una revisión narrativa utilizando las bases de datos MEDLINE, CINAHL, PsycINFO y Cochrane Library para identificar los estudios publicados en inglés y en español de 2002 a 2018.
Se incluyeron 46 estudios, identificándose cinco categorías: 1) «Necesidad de saber»; 2) «Satisfacción del familiar con la información recibida»; 3) «Impacto de la información en las experiencias de los familiares en la UCI»; 4) «Percepciones de las enfermeras y médicos sobre la transmisión de información», y 5) «Proceso de información en la UCI».
La aportación de información honesta y veraz a los familiares de los pacientes críticos es esencial para reducir su ansiedad e incrementar su control, aunque parece que esto no siempre es adecuadamente realizado por el personal. La implicación interdisciplinaria en la aportación de información puede ser beneficiosa para los familiares y los profesionales de las UCI. Esta revisión aporta una nueva comprensión acerca del proceso de información a los familiares de los pacientes de la UCI y puede utilizarse para mejorar la calidad y la humanización de los cuidados en dichas unidades.
Information is one of the most important needs of families of critical patients. Healthcare professionals also identify the great value of communication with families to reduce their anxiety and stress. Despite this, families may feel inadequately informed, causing added suffering. The purpose of this study is to provide an understanding of both families’ and healthcare professionals’ perspectives on information giving within intensive care units (ICU).
A narrative review was conducted using MEDLINE, CINAHL, PsycINFO databases and the Cochrane Library to identify studies published in either English or Spanish from 2002 to 2018.
47 studies were included, and five categories were identified: 1) “the need to know”; 2) family satisfaction with the information received; 3) impact of information on families’ experiences in the ICU; 4) nurses and physicians’ perceptions of information transmission, and 5) information process in the ICU.
Providing honest and truthful information to the families of critical patients is essential to reduce family anxiety and increase family control, although this often appears to be inadequately accomplished by staff. Interdisciplinary involvement in information giving may be beneficial for both families and ICU professionals. This review brings new understanding about the process of information to families of ICU patients and it can be used to improve the quality and humanization of care in the ICUs.
Family and health professional experience with a nurse-led family support intervention in ICU: A qualitative evaluation study
2020, Intensive and Critical Care Nursing
To investigate family and health professional experience with a nurse-led family support intervention in intensive care.
Qualitative evaluation study.
A twelve-bed surgical intensive care unit in a 900-bed University Hospital in Switzerland.
Data were collected through 16 semi-structured interviews with families (n = 19 family members) and three focus group interviews with critical care staff (n = 19) and analysed using content analysis strategies.
Four themes related to the new family support intervention were identified. First, families and staff described it as a valuable and essential part of ICU care. Second, it facilitated staff-family interaction and communication. Third, from staff perspective, it promoted the quality of family care. Fourth, staff believed that the family support intervention enabled them to better care for families through increased capacity for developing and sustaining relationships with families.
An advanced practice family nursing role coupled with a family support pathway is an acceptable, appreciated and beneficial model of care delivery in the inttensive care unit from the perspective of families and critical care staff. Further research is needed to investigate the intervention’s effectiveness in the intensive care unit.
Implementation of a Standardized Patient/Family Communication Bundle
2020, Critical Care Nursing Clinics of North America

View all citing articles on Scopus

Funding/Support: This research was funded by the National Institute of Nursing Research, National Institutes of Health [Grant RO1NR008941].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

View full text

Chest

Original ResearchCritical Care MedicineEffectiveness Trial of an Intensive Communication Structure for Families of Long-Stay ICU Patients

Background

Methods

Results

Conclusions

Trial registry

Section snippets

Materials and Methods

Results

Discussion

Conclusions

Acknowledgments

Crit Care Clin

Chest

Chest

J Crit Care

Chest

Am J Med

Chest

The long-term outcomes of mechanical ventilation: what are they and how should they be used?

Respir Care

Growth in adult prolonged acute mechanical ventilation: implications for healthcare delivery

Crit Care Med

Brain dysfunction: another burden for the chronically critically ill

Arch Intern Med

What are the needs of families of critically ill patients? A review of the literature since 1976

Heart Lung

Measuring the ability to meet family needs in an intensive care unit

Crit Care Med

Family satisfaction with care in the intensive care unit: results of a multiple center study

Crit Care Med

Survival and quality of life: short-term versus long-term ventilator patients

Crit Care Med

Composite outcomes in the chronically critically ill: survival, location, and cognitive status at four months

Am J Crit Care

Original Research
Critical Care Medicine
Effectiveness Trial of an Intensive Communication Structure for Families of Long-Stay ICU Patients