SCCM Resource Library-Family Presence in the ICU: Does It Make a Difference?

Video Transcription

Today we have, uh, three great speakers, uh, uh, to discuss family, family presence in  rounds in a, kind of a multidisciplinary fashion. What I'd like to do is to have, let the speakers  speak for about 15 minutes each and then we'll bring everybody up on the stage for, uh, kind of  a conversation at the end of that discussion, uh, of their talks so we can, uh, have an interactive,  interactive talk. So first speaker today is, uh, Katherine Roberts. You are good to go.  Good morning, everybody. I think it's still morning. Right. So my topic this morning is the historical foundations of family presence in the ICU.  And the three of us were talking and we started to laugh a little bit at the title. But then we realized we have been talking about this for quite a while.  So historical foundations does seem a bit appropriate. I have no conflicts of interest to declare. I thought we would start off by talking  about what is family presence in the context of this morning's discussion. How long have we been talking about this? And why are we still talking about this?  Because I had a few friends say to me, you're giving a talk about what? Why are we still talking about this? And a few of your heads are nodding. And yet you are in the room.  So there are some reasons why we are still talking about this. So for purposes of today, we'll talk about visitation, invasive procedures, and then  where we'll really do a deeper dive. And I say we, meaning Andrea and Tessie, we'll do a deeper dive into rounds. How long have we been talking about this?  We've been talking about this for more than 20 years. And if you go back to Doyle's paper from 1987, we've been talking about this for a lot more than 20 years.  And I'm going to show my own age now by saying this, but I took a look at my own CV. And apparently the first time I talked about anything related  to family presence at SCCM was in 2003.  Then came back, talked about it again in 2010. And now here I am again in 2020. I'm thinking, hopefully, it won't be me in 2030.  And perhaps it will be somebody else doing it at that point and that the conversation will be a bit different. So why are we still talking about this? Still challenging.  It's not easy.  And at times it can still be a pretty emotional conversation. And if you take a look at some of the abstracts that are being presented this week,  a lot of the conversations are pretty similar to the conversations we had in 2010 and we had in 2005 and we had in 2000. And you go back, and we were just talking about that  before we started.  And I do want to call out the fact that, yes, you have three pediatric providers speaking today, but this isn't a pediatric conversation per se, right?  We're talking about family presence across the lifespan when we have that conversation today. And I think it's important to call that out.  So I've broken all the rules about what you should do in a slide. But when it came to looking at the history, I thought let's try and put it all in one place  and then I'll break it down in this slide a bit. So yes, I went back to the late 1800s. But part of the reason for going back to the late 1800s  is when you think about when did patients really start to move into the hospital setting and not receive as much care in their home? Think about the late 1800s.  And that was the norm that the patient went to the hospital,  in the US at least, the family did not spend time in the hospital. And in the pediatric world, child was almost essentially dropped off at the hospital  and the family didn't get to see the child, spend much time with the child until it was time for the child to go home.  Jumping forward to the 1960s, ICUs are becoming far more common in the hospital setting. Moving into the late 1960s, pediatric ICUs are really starting to come into existence.  Going forward, 1980s, 1990s, I'd mentioned the Doyle paper earlier and that will be in the references in the slides. So they had published their experience  at Foote Hospital in Michigan. And they had been doing some work allowing families, offering families the option really to remain present during resuscitations in the ER.  And that's the first publication where we see some work there. And they'd had some very positive experiences with that. In the early 1990s,  that's where we started to hear about this concept of family-centered care that really did start off in pediatrics. These days we know it as patient and family-centered care,  but originally we knew it as family-centered care. And talking a lot from a pediatric perspective about the fact that the family is the constant in the child's life,  and that as providers, as healthcare providers, we were the ones who were just visiting. It wasn't the family that was just visiting.  Partially as a result of that work, partially as a result of other things, you start to see more liberalized visitation in the pediatric setting,  more in the labor and delivery setting, but not in the ICUs. The ICUs still remain quite restricted in the pediatric settings as well. And in the adult setting,  they're still very, very restricted in that timeframe.  All right, moving into the early 2000s. The IOM, at that point in time, the Institute of Medicine, now the Academy of Medicine, recommends that we become more patient-centered  in our healthcare systems. In 2004, the Institute for Healthcare Improvement, in this really Don Warwick, puts out a challenge that we should liberalize visitation.  And he doesn't just put out that challenge to pediatric settings, he puts out that challenge to adult and pediatric settings.  In 2004, the American Association of Critical Care Nurses issues a practice alert for family presence during resuscitation. Really what that did was summarize the evidence  that was out there to date and give some guidelines for how you could support families and family presence during resuscitation. And it talked about offering the option  for families to be present during resuscitation. In 2007, the American College of Critical Care Medicine put out clinical practice guidelines for supporting families in the ICU.  And before I move into 2010, so how many of you in the room, because I know some of you were involved in any of that work, that practice alert from AACN,  or the clinical practice guidelines from the college? There you go. I see people in the room that I know were involved, so the hands were kind of like this,  but there are a number of people in this room today who've been involved in this work.  Moving into 2010, a lot of revision happens in some of the work. So in 2010, AACN revises the practice alert for resuscitation and invasive procedures, having families present.  In 2011, AACN then, sorry, try that again. AACN then revises the practice alert for visitation in the adult ICU.  2016, AACN revises the practice alert for family presence during resuscitation and invasive procedures. AACN did a lot of revision in here,  and I have things a little bit out of order in there. So you can see they'd also revise the visitation in the adult ICU a few times.  And then most recently, and this was a huge body of work that came out of the college in 2017, the clinical practice guidelines for family-centered care in neonatal,  pediatric, and adult ICU were revised. And if you take a look there, notice the change in name. So the original name in 2007 had been support of the family in the ICU,  very intentional wording that was used in 2017 for family-centered care in the neonatal, pediatric, and adult ICU. If you've not had a chance to take a look at that document,  I highly recommend you take the time to look through those guidelines. So the reason our professional societies take the time to bring the experts together  to do the review of the evidence is that they know there's a gap. So there's research that's coming out. We're all reading the research,  but we're also living the reality at the bedside of trying to incorporate families into the work that we do to partner with families to have the best outcomes for patients.  But it's hard. It's not smooth. Sometimes it is smooth. Sometimes it goes really, really well. And other times it's really, really challenging.  The societies have recognized the gap. They're trying to give us strategies. They're trying to tell us what the best practices are that are based on the evidence,  and then give us recommendations and guidelines. The other thing the college has done, when you look at their guidelines, they also end it with recommendations  on what are the research priorities? What are the areas that we need to focus on going forward so that we continue to make strides in this type of work?  And they do that with all the guidelines that they publish.  So I mentioned this idea of patient and family-centered care, and I think it's worthwhile to just take a quick look at the key concepts.  So the Institute for Patient and Family-Centered Care is a group that's done a ton of work around patient and family-centered care. Key concepts when we think about this.  So what is it? It's an approach to the planning, the delivery, and the evaluation of healthcare.  And the idea behind it is that the care we provide should be grounded in mutually beneficial partnerships, and those partnerships should be between  healthcare providers, patients, and families. When we talk about the patients, obviously there's a developmental component to that. If I'm taking care of a neonate,  if I'm taking care of an infant, they're not as involved in decision-making around their own care. If I'm talking about an adolescent, if I'm talking about an adult,  they're more involved in decision-making around their own care.  I folded and underlined this third bullet because it's really important when we're talking about family presence. The idea isn't that I, as the healthcare provider,  define who the family is. The idea is that the patient defines who the family is for the patient. When it comes to the child, it will be that their family defines who the family is.  I'm not the one making that definition, and I think that, for a lot of us, especially 10, 15 years ago, that was an adjustment because I think often we had very set definitions  in our own head of who the family was.  And then last but not least is that the patients, especially when they're the ones who are capable of doing so, they determine how their family will participate  in care and decision-making.  So I'd mentioned earlier, for purposes of today's discussion, we're talking about visitation, resuscitation, invasive procedures, and rounds. There is a larger body of evidence.  We've been looking at this for a long time. More abstracts at this year's Congress as well. So know that what we talk about today is very high level.  You could do a deep dive into each one of these topics, and you could spend more than an hour on each one of these topics. We don't have the time to do that today.  So visitation. What I did pull out was a bit more of what's in the ACCM guidelines and what's in the most recent ACM practice alert.  So the guidelines from 2017 says that family members of critically ill patients should be offered open or flexible presence. We'll talk about what that means.  At the bedside that meets their needs while providing support for staff and positive reinforcement for staff to work in partnership with families to improve family satisfaction.  So open or flexible presence, and we use a lot of words. We talk about open visitation. We talk about flexible presence. We talk about unrestricted presence.  You'll see in different documents. What does that mean? Essentially, it's 24-7 is what that means.  Support for staff is key, and I should have underlined that and bolded that as well. And support for staff can take on many different things.  Some guidelines, policies, consistency, so staff know what this should look like, but it also means support for staff when the conversations are challenging.  Who do I go to when conversations are challenging? When I think there's risk for me, when I think there's risk for the patient, who do I go to, where do I get that support from?  And this idea that it's supposed to be in partnership. ACM's practice alert uses some different language, but some of the same key concepts are there.  Facilitate unrestricted access, so another term, of hospitalized patients to a chosen support person. According to the patient's preference,  an ACM calls out an unless in their practice alert. Unless the support person infringes upon the rights of others and their safety, or the support person's presence is medically  or therapeutically contraindicated.  So I was looking back in those slides from 2010. I think the title of that one that I was assigned was open visitation, what do we do with the family? I was assigned the title.  And I had apparently put this in those slides, where the wild things are, and I talk about visitation. But the point in that was that it's not intended to be this.  It's not intended to be a free-for-all. There should be guidelines. In anything we do, it's meant to be a partnership. So it's not a free-for-all on our part, staff side.  It's not a free-for-all on the family side either, or the patient's side. Partnership, guidelines, communication. So get rid of where the wild things are. Go from there.  So as we talk about open, flexible visitation, what are we seeing in the research? Now, much of the research that's been done,  it's descriptive studies, it's qualitative studies today.  So you can see up here, potential to reduce delirium and anxiety, increase family satisfaction, increase family knowledge, and that's knowledge about the care of the patient.  Engagement in care and communication,  improved relationships between staff and families. Finding challenges. A lot of the staff have talked about, and this is nurses, this is physicians,  this is other roles involved in the care team. Finding that balance between caring for the patient and meeting the family's needs.  There is definitely an inconsistent level of comfort between different practitioners. The resources that are needed to support families, finding those and putting those in places.  Not all family members behave in the best interest of the patient.  Many do, vast majority do, but not all. Potential to increase staff burnout. There's one paper that's talked about this so far. Small study, but it's been called out  in many of the guidelines, so it's just worth mentioning. Clinician preference. There are a lot of abstracts that have come out recently talking about clinicians' preference  of not having open visitation. So how flexible are we? I'll go through these quickly to make sure we talk about resuscitation as well.  Some of our European colleagues have done a better job surveying than we have. We're not very open and flexible in our visitation. So these are in adult ICUs.  There's not been a recent pediatric study in the U.S. looking, but in Italy, Giannini's done some work there.  Only 12% of the Italian PICUs had unrestricted, meaning 24-hour-a-day visitation. And he had 100% response rate, which I thought was fantastic. So that was in 2011, he went back,  he looked again in 2017. They had four fewer ICUs in Italy at that point, and they'd gone up to 23%, so they'd seen an improvement.  Shifting quickly to resuscitation invasive procedures, all of these groups have put out statements about offering families the option  to be present during resuscitation and or invasive procedures. Every one of them calls out that we should also assign a staff member to be present to support the family.  So you can see the ACCM guidelines are up here again. The AACN practice alert from 2016, again, calls out offering it as an option. So it's not saying make it mandatory.  It's offering it as an option and calls out the need to support the family. AACN just uses different language down here. AACN also calls out the need to have some kind  of written practice document so that staff know what the policy is and what it is they're supposed to be doing and what their resources are.  Benefits that have been found in the research thus far, families believe their presence is beneficial to the patient. When it comes to invasive procedures,  there's been some research thus far showing that patients have found that having their families present is beneficial. We're seeing some evidence that there's a decreased  signs and symptoms of PTSD, depression, and traumatic grief when patients, not only when patients, I was gonna say when patients have died, but not only when patients  have died, but when the hospitalization itself has been a traumatic experience, and an increased understanding of the care of the patient for families.  Challenges and concerns, there's inconsistent support amongst clinicians for this. There are inconsistent resources available to support families.  Clinicians still express a lot of concern about potential for family member distress. The research that's been done so far doesn't necessarily support that that distress exists.  There's worries about family member interference in care. The number of reports of that actually happening are quite low. Distractions for the healthcare team are a big concern.  There are medical legal concerns. Again, reports of the actual incidents are quite low.  So what do clinicians and families think? Mixed support from clinicians. In the studies published thus far, nurses have been more positive than physicians,  and more experienced providers, that's across nursing and medicine, are more positive about it than less experienced clinicians. Families would like to be offered the option.  Not every family wants to be present. They'd like to be asked, but they don't all want to be present. And having done it once, not every family wants to do it again.  These two lovely ladies are going to talk to you about rounds in just a moment, and they're so happy that I put their pictures in the slide.  So in closing, looking forward to 2030, one of my challenges to the audience, many of you have done research in this area. My hope is that you'll take a look at not only  the ACCM guidelines for some of the research priorities, but that you'll work together to think about what are the other research priorities going forward.  If you look back at abstracts that were presented 10 years ago, we're still talking about a lot of the same things. Please collaborate together and think about  what are the different research questions we need to be asking? How could we be having a very different conversation five years from now, 10 years from now?  You know, this was something that I had honestly kind of stumbled upon. I was working on a talk for something very different, but it really resonated with me,  this idea that we envision a future in which individuals, families, and communities are understood to be the very reason our healthcare system exists.  And that those who are caring, teaching, learning, or otherwise working within the system must partner fully and effectively with families  to foster optimal health and wellness for all. We're going to be interacting with families. They're part of our patients' lives.  And unless we find a way to partner really effectively, we will still be having the same conversation in 2030 that we're having right now.  My hope is that we won't be having that same conversation. So thank you for your time today.  Thank you.  Our next speaker is Andrea Klein from Children's Hospital of Michigan.  Good morning. It's a pleasure to be here. And I'd like to thank the Congress Planning Committee for inviting me to speak and spend time with you this morning.  It's also a special treat because as I was sitting and listening to Catherine, I was thinking, gosh, we've been friends for a long time.  And I think it was probably at one of the Congresses that we became friends. And so that was a long time ago that we met and started to become friends.  So it just highlights the importance of getting involved in your professional organizations. Okay. So we're going to talk about the nursing perspective for family-centered rounds.  And for better or for worse, I don't have any conflicts to tell you about this morning. Nope, wrong way. All right. So some of the objectives for this morning.  We're going to talk a little bit. So we're going to do an international flair on this topic. So we're going to talk about international nursing perspective on the benefits,  as well as some of the challenges of family-centered rounds. And then we're going to talk a little bit about the strategies to increase engagement of nursing  in family-centered rounds.  So why use patient and family-centered rounds? And Katherine already talked about this. So just very briefly, increases efficiency. So the whole team is there, the family's there.  Everyone gets to know what the plan is for the day. Put some of that up on the whiteboard and everyone's on the same page. Can facilitate timely discharges too.  So what happens, rounds in the ICU can be eternal, right? So hours later, the team comes back and lets the nurse know this patient's being transferred,  this patient's being discharged. And then the work starts to get done. But if everyone's on, and the family has to call and maybe they live a couple hours away,  they need a transportation. So it can facilitate some of the movement in terms of discharge transfers for not only the staff, but also for the families.  Increases communication and outcomes. The outcomes piece, a little bit of information about if you have the family there on rounds and the information about the patient  or the child is being presented, and they can sometimes can be uncomfortable, but sometimes they can correct us and say, hey, that's not the formulation of medication  that this child is on at home. This child does much better with this formulation. We can make changes. We can optimize our management during rounds as well.  Okay, so what do the nurses think about family-centered rounds? So a little bit of a spoiler alert here. There are some different perceptions from nursing around the world.  So what we think in the United States as nurses is gonna vary across the world. So we'll talk just a sampling from some different countries  as we go further through this presentation. And to recognize, you know, Catherine presented the history, right? It's been a long time that this has been developing.  And so, you know, as I became a bedside nurse a long time ago, you know, I remember in the pediatric ICU, there were visiting hours. Those family members, they had to leave  during nurse-to-nurse report. They had to leave for rounds. They weren't staying at the bedside. Fast forward, you know, a couple decades now,  and when we create new pediatric intensive care units, we're building a space for that family, and we're building a space for them to be able to stay overnight with those children.  So you can see this is a process. This isn't something that happens overnight, but we've come a long way, and it's really evolved.  So when looking at things globally, really around the world and what nurses think about the families, there are a few, you know, universal themes that came out,  and that the really, that the patients and the, I mean, the parents and the families know their child or their family member best, so they recognize  that they're really the ones intimately involved, and they know this person best, that they're really unable to think about that person with also thinking about the family  of that individual as well, and that it's important for the family to be close. So those were things that came out as themes globally when it came to nursing, but we're gonna talk  a little bit now about the United States, and really that nurses are more satisfied when family-centered rounds are implemented in their units, so overall happy with them.  They enjoy the increased communication among the different disciplines as well as having the family there, and then this paper from 2015 by Amanda Levin  looks at provider perception of family presence during family-centered rounds, and you can see here with a blue outline what the nurses think, and so there were 64 nurses  that were included in this, and you can see that about 53% said that the families then provided information during rounds, so they contributed during the rounding process,  and almost 100%, 97% of these nurses felt like families should be routinely invited to participate in family-centered rounds, and the presence of family when it came to this,  66% thought that they might limit discussion that's happening during rounds, and about 22%, so not as high as some of their counterparts,  thought that it might prolong the duration of rounds itself, and then looking at, does it require them to explain as much after rounds to the family?  Well, 66% felt like they spent less time explaining to the family what the plan is for the day, where we're going, what the trajectory of illness is  for these patients, so those were some of the findings from Amanda's study. Now, also in the United States, there was a cross-sectional survey study  done in a pediatric medical surgical intensive care unit, and it was really to compare the experiences and the attitudes of healthcare providers and parents  about parental participation in morning rounds, and so there were 131 healthcare providers that were included in this, and you can see  some of the differences here between nursing and physician, and so with the statement, sometimes it's inappropriate for parents to attend rounds, you can see 40% there  for the nurses, a little bit different than physician counterparts, a provider should return after rounds to discuss the plan with the family,  almost greater than 90% of the nurses thought so, and so while it's important that they're there and they're getting a lot of information,  the nurses still felt that it was important for a provider to come back and discuss the plan again after rounds, and then in terms of parental presence  limited discussion on rounds, not quite 60% of the nurses felt like it did, and then on the physician side, almost 90% felt that maybe it's gonna limit  the discussion that's being had on rounds, and then overall, the nurses were more likely to report that they believe that the family members understood  the information that was discussed on rounds, so about 30%, and certainly we don't need them to understand how we're calculating the fluids or how we selected which inotrope,  we don't need them to understand that, but we want them to be able to understand the big takeaways, the big pieces of trajectory, what the plans are for the day,  so some of those big pieces, it's important that they understand, but some of the minutiae, probably not as much. So what happens, and what are some of the challenges  to get the nurse to the bedside to be there during family-centered rounds? So you can see here on the graph, medication administration can impact it, so they might wanna be there,  but they need to go back in the room and they need to administer a medication, maybe they have too heavy of an assignment load, so maybe they have too busy intubated kids  and that they can't manage it, they have other patient care needs, patient needs to be suctioned at the time, they need to take a new admission,  some other pieces are unawareness of when rounds occur, so they wanted to be there, but they weren't sure what time to expect the team, so they couldn't really plan for it,  so instead, they had to be attending to some of the patient's needs. Sometimes, a nurse might have an assignment where they have a child or an adult that's on two different teams,  so maybe they have a surgical patient and they have a medical patient, and so sometimes, we know that those rounds can sometimes intersect, and so sometimes,  a nurse just isn't available because they're rounding with another team. Perhaps they're off traveling to MRI or CT with their patient, and then sometimes,  even when they start there and they're there when rounds start, they're not always there when rounds finish because now they're called away, so there are sometimes some challenges  for the nurses to either get to the rounds when they start or stay there once they've started.  So we're gonna move a little bit away from the United States now. We're gonna talk a bit about a paper that was done from the Netherlands,  and this was a descriptive qualitative study. It involved interview as well as non-participant observation and there were 20 participants. 10 of those were nurses, so half of them,  and the themes that came out from this was that the nurses were willing to work together with the families for them to be present on medical rounds.  They considered that the family members were really a valuable resource in terms of providing any input on rounds, but they wanted the rounds to take place  away from the patient bedside, and we'll talk about that on the next slide, and they really see themselves as a family mentor, an advocate, a coach, so that they're really there  on the family side to join together with them to improve the patient and family experience,  but where they had some challenges is when there was some ambiguity, and their perception was different from the family's, and so they said, okay, well, the family says,  oh, he had a really terrible night, and he was awake all night, and he was in all kinds of pain, and then from the nursing side, it was, well, gosh, I felt like he slept a lot,  and he got one dose of morphine, and so sometimes the nurses felt like they were put into a space that was a little uncomfortable  because they see themselves as a patient and family advocate but sometimes they see themselves perceiving things to be a little bit different than the family,  and so sometimes they felt like that put them in this awkward spot. All right, so same study we're talking about here, but you can see, so this comes from their paper  in that they suggest that rounds take place away from the bedside, and this should be an ideal seating situation, so we have the parent  and the nurse sitting next to each other right here, and really because the nurse is there  as their advocate and their coach, and then you can see the physician on the opposite side of the table, and so a quote from this paper,  sometimes, of course, finding the right words is difficult because you try to do it in a way that doesn't put the parents on the sidelines. You also don't want to contradict them  because it is their observation, their feeling, but you also want the doctor to know if we see it differently as nurses.  So this paper came out of Turkey, and this is nurses' perceptions to barriers to implementing family-centered care in a pediatric setting, and this is a qualitative study,  and so a little bit different I want to just mention is that this isn't about family-centered morning rounds. It's really about inviting the family to be present  during the time of nursing handoff, so a little bit different flavor, but I can tell you during my career, allowing families to be there during nursing handoffs  was really the first thing that came along, and then later came, okay, it's okay for the family to be there during the whole rounds. So, okay, so what they found was that they did,  similar to those global themes that we talked about earlier, they felt that the continuity of the family and the child's life was important,  and they believed that nurses should empathize with family and understand their feelings about the hospitalization,  but when it came to the families being there during nurse-to-nurse report at the end of a shift, they felt like it increased time spent on nursing rounds.  The family asked too many questions. They actually could be an obstacle to the care, that they had a lot of diversity and backgrounds of their patients and families,  so they felt like sometimes that was challenging because they would bring different pieces, different things to the table. They also felt like, gosh, you know,  I think if they're there hearing us talk, not fully understanding the lingo that we're using and exactly what we're talking about, it's gonna cause more stress for them,  and that all of that could lead to them misunderstanding what they're talking about, but not wanting to take the time to really explain all the details  of what they're talking about. So these were some quotes that came out of their paper. However, we're changing shifts at rounds, so I do not think the participation  of the family is necessary. This could be a waste of time. Our rounds already take one hour sometimes. So these are just some quotes,  and at the bottom, all the nurses in the study did have bachelor's degree, but they really felt ill-equipped to be able to add this other piece, to add the family-centered care,  to be able to address family questions, concerns, really, you know, put the greater scope when they ask questions, perhaps about trajectory of illness  or what to expect with the next step of their care.  So what can we do to foster nurses to embrace family presence on rounds? We've heard there's a relatively big variety in terms of globally, so around the world,  how far we are in terms of embracing this. So it really would be unit-specific, center-specific on exactly what is needed. So this was a nice paper that came out in 2016 by Aragana,  and a quality improvement project to increase nurse attendance on patient pediatric family-centered rounds. And so this was a resident-driven project,  and they used surveys and they used focus groups to really figure out how can we get the nurses to the bedside to participate in family-centered rounds?  And so their goal was to increase nursing attendance up to 80%, and they didn't quite get there, but they did make a nice increase. They increased nurse attendance from 30 to 59%,  and it didn't matter what the nurse-to-patient ratio was in that, so that was not a factor.  But some things that came out as they did these focus groups,  the nurse really needed to know when the team was going to be rounding. And so different, there's some different approaches.  The nurse can be paged, the person, some centers use electronic boards that the fellow or someone on the provider team would estimate and estimates  in the morning what time they anticipate being at each bedside. So that they can prioritize which patients need to be rounded on first,  give an estimate of how much time they think they'll need with each patient so that then the rest  of the team, whether it's respiratory therapy, nursing, family, can have an estimate. And of course, this is fluid of what time to expect the team to be there for rounds.  And then also, with something simple, but just rounding on an individual nurse's patients all  at one time, so that let's say they have bed space 14 and 16, it's more helpful for the nurse if they can do bed space 14 and 16 and skip 15 and come back to 15.  So something very simple. And then considering, should there be an additional role of another nurse that can come  in during rounds so that each, when they move to each patient, the team moves from patient to patient, that then this person can be there to tend to the patient's needs  so that the nurse can then be involved fully in family-centered rounds. And it also was proposed that maybe, you know, if rounds are generally between this time  and this time, are there medications that maybe we can alter so they don't need to be administered during that time? Certainly, that's not going to happen in all cases.  But could that be a consideration, too? So all things that came out of this project.  There are also, Cox in 2017 published an implementation of family-centered rounds checklist.  Very helpful. I don't have the whole checklist listed here, but there is the reference.  And so all the different elements are listed here on this slide. So the nurse is present. The introductions are made. There's an assessment. The whole plan is summarized at the end.  So the family can kind of put it all together. The family has time to ask questions and the discharge goals. And then any orders that are entered during rounds are then read back  so that everyone's on the same page. And so it was found that this, you know, really improved family engagement, but also the culture of safety.  So it's really everyone being there on the same page.  All right. And then effects of an educational workshop on pediatric nurses' attitudes. So what they did is this group had five didactic sessions  within a month that the nurses would attend. And it would include information on what's the evidence about family-centered rounds so they could bring them up to speed on that.  What are some tools that you can use? They provided them with a tip sheet. They had individuals that could come and share their experiences.  And so after doing this quality improvement project, so this was done in Canada, there really was a positive impact on nurses' attitudes and beliefs and buy-in,  which can be so important in terms of family-centered rounds. All right. So this quote, nothing about me without me. And I'm just going to expand that to, you know, the family too.  All right. So just to wrap it up here, really nurses recognize the needs for families to be present and involved in daily rounds.  But there is international variability on the implementation of this. And we talked about really how it's a process of getting from point A to point B.  And optimizing components of rounds may increase nursing satisfaction as well as nurses being available during the time of rounds. So thank you very much. Thank you. Thank you.  And our third speaker today is Tessie October from D.C. Children's.  Hello. Thank you.  I am going to speak to the physician perspective after my co-speakers did such a great job of laying out the foundation and talking a little bit about nurses' presence.  Nothing to disclose.  I'm hoping to first talk a little bit about how having families present on rounds actually can increase our physician workflow.  And then spend a little bit of time talking about some of the concerns that physicians have about having families present.  But I want to spend the bulk of the time talking about strategies to engage and empower families and how we can mitigate some of these worries that physicians have about whether  or not families are present on rounds. So I'm hoping to give a lot of tools of what is being done across the world to engage families.  I'll start by saying that first, as a pediatrician,  we definitely see the parent as part of the team. And I don't think that that's different for adult medicine as well. Because these people are often the caretakers.  And they bring a perspective about what's going on with that child or that family member that is so unique and something we wouldn't have otherwise.  And in pediatrics in particular, we really think of the parent as the expert in their child's care, mainly because they know everything.  They know exactly what position is the most comforting for their child. They know what happened. And oh, that's not really red man syndrome.  This is actually a reaction that my child had with vancomycin.  But also, part of being in the ICU, especially as a parent, is that your job is to be a caretaker for your child.  And you lose some of that sense of control when your child is in the ICU. Mainly because we strip that in a lot of ways, right?  The normal things that you do to comfort your child, you're not able to do.  You're also not able to feed them and do all the things that you normally would do as a parent.  And I will say that why this is so important is there's a body of literature that started  with one of my research mentors, Dr. Pam Hines, who looked at the role of being a good parent. And we've seen this role of good parent that has been translated into the good spouse,  the good daughter, the good son, and it's not a judgment. It's not that we as providers are saying they're good or bad.  It's a parent-derived term, a family-derived term, where they say that I am fulfilling my role of being a good parent for my child, and what does that look like for me?  And so we did this work in our ICU to say, what is it that allows you to fulfill your own internal definition of being a good parent to your child?  And we found the major themes, we found 12 themes and ranked the themes. The top themes were focusing on my child's health, putting my child's need above my own,  making informed decisions, and making sure my child felt loved. And what that means is that families are telling us when they have these things that allow them  to be a good parent to their child, they're more likely to make decisions for their child that fit their definition of being a good parent.  What was interesting to us is that we also looked, this is the Levin study,  we also looked at why families participate in rounds. And we were surprised to see such a significant overlap between what allows them  to fulfill their role of being a good parent and why they actually participate in rounds. So it helps parents and families to participate in rounds  because not only does it fulfill their role of being a good spouse or a good parent, but it also gives them control back that they've lost by having their child  or their loved one in the ICU. So I don't feel like I need to spend a lot more time talking about why it's important for families to be in the ICU, to be present on rounds.  I think my colleagues did such a fabulous job with that.  What I'm going to talk about is why in the, what do we see in the literature as the major barriers that physicians identify as to why they don't participate in family,  they don't want families to participate. And these are the ones that come out over and over again. It slows the team down. We're not able to teach effectively to our trainees.  What about team disagreement? What do the families think about that when we are not on the same page? And what about those medical errors? Will they notice? Will we talk about it?  Do we have to talk about it now that they've heard about it? And there are some families who don't want to attend, and it's anxiety-provoking  to actually be participating in family-centered rounds. So how do we actually figure those things out?  And so what I'm going to spend the rest of the time talking about is some strategies that lots of wonderful centers have used to address some of these.  I'll take slowing down the team and affecting teaching together because they often coexist. And I will say that what Levin showed in this study was that it's very, it's true.  We've seen it in multiple studies across adult and pediatric ICUs that it does add time. The average family-centered rounds encounter across most studies is about 10 minutes  when a family member is present and about 8.9 minutes when families are not present. And it may not seem like a big deal. We're talking about a minute.  But if you're rounding on 40 patients, a minute actually makes a difference. And so the other thing that people often bring up is that I can't teach effectively to my trainees.  I don't want the family to see that this person doesn't know what's going on or we're talking above their heads by using a lot of medical jargon.  So I wondered about what strategies have been done across several studies to look at these.  The one that I found to be really exciting was a group out in UCSF, this is an adult unit, and they scheduled appointments. Now, this does require to actually have a coordinator.  So they had a coordinator who was non-physician, non-nursing person who is .5 FTE was what the position was slated as. And this coordinator met with the team leader and said, hey,  tell me all the factors that matter. So for rounds, who needs to be present, which consultants are part of the team for each patient, and then they would gather all that information  and then they would send a text page to the bedside nurse to say, hey, these are the structure of rounds. Rounds last about 10 minutes for each accountant.  This encounter might take 15 minutes because this patient has a lot of consultants and more issues. And so they would actually have appointment times.  And what it allowed the families to do is to not miss that rounding encounter if they wanted to.  We all have been in that situation where the family is waiting and waiting and waiting. They go to get a cup of coffee and that's when we round. And so this allowed them to do that.  But what I loved that they also did was they added a teaching appointment as well. So somewhere in the middle of rounds, they added a 10-minute session that was outside  of rounds that the team leader decided to use that appointment for teaching. They also did a couple of really cool strategies where if they ran behind time,  then they made an executive decision to skip the next appointment and then keep all the other appointments on time and then they'll come back to that one at the end.  Those are some of the hurdles that they've sort of found throughout, but they were able to figure out ways around it.  What we've done at our institution, and I'll show you a video next, is that we've found that when families knew what rounds were, that we created a little bit  of structure that allowed families to know, okay, the doctors speak first, our nurses speak last, and then you're, you know, included at the end.  So not only just gave them structure, but also gave them information about who everybody else was on the team. And I'll show you just a small clip of this video.  Intensive care unit at Children's National Medical Center, sometimes referred to as the PICU. And because we're pediatricians, we made it into a cartoon.  So we want you to participate in what we call family-centered rounds. Imagine that rounds represent key points along your child's healing journey. We want you on that trip with us.  Rounds take place twice a day, morning and evening. On rounds, our team travels through the unit, stopping at each room to assess and discuss each patient's care.  Each team member is given uninterrupted time to speak and ask questions, including you, the parent or guardian. Everyone at Children's National values your participation as much  or as little as you're comfortable with. So what should you expect during PICU rounds? First, we do an overview to gather a complete picture of how your child is doing.  We also discuss the plan for the day or night. You'll probably hear medical terms new to you. We'll do our best to explain them.  You can also ask your nurse or a physician to discuss them with you later. At the end of rounds, we'll ask for your input.  This is a great time to raise questions, concerns, observations, or anything else on your mind.  So who is on the rounds team? There are five key players. Resident, fellow, nurse, attending, and a parent or guardian. A resident is a doctor in training who can answer.  So I stopped it there because I think you guys know who all these people are. The point of that was not only to what we also do is we tell them,  the resident is the person you ask for questions about the labs and the test results. Your attending has this body of information. And your nurse does these things for you.  But what was lovely about it is that we found that families not only knew what to anticipate for rounds, but they quickly got into the process.  And it decreased our questions that were not relevant to you as the provider, but also increased the efficiency.  I'm not going to show the rest of the clip here, but I wanted to stress there that we also told them about why it's important for them to be present.  And at the end, we gave them an out that you don't have to be present. This is not a mandatory thing, and it's OK if you choose to opt out.  If you want the video, it's on YouTube. You just would Google Children's National and Family-Centered Rounds. We give that video to every family who comes to our ICU.  They're asked to watch it before they attend a rounding encounter.  One of the other things that people have brought up in the literature as to why physicians don't want families on rounds is team disagreement.  And I don't know what your rounding encounters look like. Sometimes it looks like this, and sometimes it looks like this, where there's like an all-out brawl.  And we often think that families will look at that and say, oh my god, these people, are these people actually the ones taking care of my children or my family loved one?  And actually, families are really forgiven. Not only do they not look at this as a disagreement and conflict, they actually look at it as a compassionate discussion that  shows that there are multiple pieces in how complicated the care of their child is, but also tells them that we are all fighting for the same thing.  And so even though what's perceived in the literature from physicians is that team disagreement is a barrier to family-centered rounds, that's not how families see it.  Families see it as actually a good thing that there is some discussion about their passionate discussion,  is the word that has been described in the literature, about their loved one. The last thing I'll bring up here is that some families don't want to attend.  So how do we actually manage that? And what we've seen in the literature is that some families actually say, it's anxiety-promoting for me to hear you talk about my child that way.  It feels like she's not even present. And it feels like you're talking about my loved one as a number or case, not as a human being.  And so it doesn't work for us to actually participate. So one of the things that we've implemented at our institution is that, has anybody here been to a Brazilian steakhouse? Yeah.  So Brazilian steakhouse, they basically come by with loads of meat. And you can choose to have meat or not. And so what you basically do, they give you a card. It's red on one side.  And it's like, stop. I have had enough. And it's green on the other side that's like, bring some more. I want some of that sausage.  And so we sort of created that model where we have a chiclet. This is outside of the room, the same place where you keep whether or not there's isolation precautions  or if an interpreter is needed. We keep this outside. And it's in control for the family. The family decides. And so they can choose to be woken up for rounds or not.  And they can change it any day that they want. So if you had a rough night and you just want to sleep in, you can change the card to red.  And in the same way, if you had a tough night but you really want to know what the heck happened to your loved one, you can change the card to green.  And this also allowed us to give families back some sense of control over something that they can control in the ICU. We have found that family gives.  So this is part of our orientation package. And we give this to families when they come to the unit. And families have told us overwhelmingly  that they find it to be extremely helpful to know that they are an active participant. And we want them to participate in rounds. Some of the other strategies that folks  have used for deciding when or not families attend rounds and giving them back some control is using telemedicine. This is one of a few studies that have looked at telemedicine  in family-centered rounds. And one of the things that they've done that I thought was really cool with this particular study is that they gave the family some control of actually  controlling whether or not they call in. So not only in this study, but there was a study in NICU that I thought was just brilliantly done where they have nanny cams.  So you guys know nanny cams. If anyone has a child, you have a nanny cam where you can just look at your baby all day, every day, even when you return to work.  And so unlike in our adult ICUs and in our pediatric ICUs where the length of stay is usually about one to two days, in neonatal intensive care units, they're quite a lot longer.  So families return back home, and they still want to be connected to what's going on with their child or be connected with the caretakers in the unit.  And so what they did in this, not in this study, but in the NICU study that was really interesting is that families were in control of whether or not they had to call in.  So they didn't have to have a navigator or an extra person to call in. So they would watch the video. And the video is just a, it has no audio. It's just a video component.  And it's just on the baby, not on the bedside caretakers. But they would be alerted that rounds are happening. And then the family calls in to the nurse.  And so that gave them back some sense of control of, you decide whether or not you want to call in to the family-centered rounds. And it didn't disturb the length of rounds  by what does happen when we use some telemedicine of setting up the equipment and calling families can sometimes be a little bit more challenging.  So there are some strategies of things that people are doing that's really helpful to getting families to participate. I'm going to end by saying there's a couple of caveats  that we didn't discuss, the first of which is that I believe that you guys both showed some of this data is that families still want you to come back,  that family-centered rounds is just one way that they expect to get some communication from their physicians in the ICU. And so it doesn't still replace those one-on-one  conversations. It's a big group. It doesn't really allow them to ask a lot of questions. And a lot of times, families will say that I felt kind of dumb, there was lots of people,  I didn't want to ask this question. Whereas one-on-one, they have no problems asking that question because we all know no question is a dumb question in the ICU.  And also, there needs to be some more considerations for non-English-speaking families. I do know that there are a couple of studies that  show having an interpreter present on rounds. I do understand that that's a resource that requires an investment from the institution. So we don't all have that as an option.  But we have to be sort of making sure that we are aware that there are usually three ways that we communicate with families at the physician level.  And it's family-centered rounds, bedside one-on-one, or during family conferences. And we are, by not including families who are non-English-speaking, we're  already giving them only 2 thirds of the ways that we could potentially communicate with them. So we have to make sure that we're  going to communicate with them outside of family-centered rounds. And I hope that we all stress that the family is an important team member.  And we all can benefit from their expertise. And having them be present during family-centered rounds, I think we're at the point where we don't have to argue that.  The next point is exactly how we're going to strategize to make it efficient for the team, as well as beneficial for our families. And with that, I'll end. Thank you.  So we have a few minutes for questions. There's a microphone up here and over here if anybody has a question. Yes.  Mark Cipolli from Lehigh Valley Hospitals. Been doing this a long time. And I think one or two of you alluded to the more experience  the care providers have, usually the more comfortable they are with this process. And one thing I would, I have a comment and a question for the panel.  What I like about having the family there in the trenches with the team is that I think they get a better understanding how sick their loved one is rather than sitting  in a sterile conference room or a waiting room talking to them not at the family's bedside. So I think that's been, that's what I really like about that.  And the other thing that you've alluded through the session is there are people who don't buy in. There are naysayers. And what do you offer as strategies  that we can do to help bring our physician and nursing colleagues along that don't exactly embrace this?  Thank you for that question. I'll start by saying you're right, that not only is it helpful to not do it in the non-sterile environment, but to get families  to understand the seriousness of their loved one's illness. I would also say that a lot of parents say that part of their parenting role is to be at the bedside.  And taking them away from the bedside is quite a challenge. And they want to be at the bedside. So they love that we're coming to the bedside to have these conversations.  And as to your question about how do we get the naysayers  to come along, I think one of the things that has been shown is experience, right? That the more experienced the provider, the more likely they are to see the value of having  families present on rounds. And then the second is trying to think about what is it that they're worried about, and how can we mitigate those? And what I alluded to in my slides  were that what has been described in the literature is that it slows down rounds. So how can we actually make rounds more efficient so that we include families?  And also, data also helps. And we know that when families are present, it does increase the length of rounds. But what has been shown in quite a few studies  is that what actually increases are physician behavior changes, not actually the length of time that families are speaking.  So on average, once families do speak on family-centered rounds, they speak about 20 to 25 seconds. And yet, they can add about two minutes to the rounding encounter.  And so having that data often helps me to talk to some of my colleagues and say, you know, they only spoke for 20 seconds. So it's not that bad to have them present.  The other strategy in conjunction with all of that, because the data is, right? So we all like data. And the data helps. It's that empathy piece. So that conversation around, if you  were in that family member's shoes, if it was your family, or if you were the patient, what would you want? What would be supportive to you?  And sometimes, that can help turn the conversation a bit while still talking about, what are your concerns? What is it you're worried about having the family members present?  And sometimes, that's where I've been able to get kind of that foothold in the door to make a difference in the case. So let's try this. And let's see how it goes.  OK, what worked in this one? What didn't work? What do we need to change for next time? And that's where I've been able to make some headway.  There's still some people I've not made any headway with, to be very honest about that. And I'm glad you pointed out at the end that this is not always a substitute for one-on-one.  When we first started embracing this, I said, oh, this is great. You're going to save time. You don't have to come back and talk to them.  But in some situations, that still needs to be done. And I think it was a very good point that you made. Thank you.  Hello. Excellent talk. My name is Shannon Solt. I'm actually a third-year fellow at UNC. And my research project is virtual family-centered communication.  I was wondering if it's actually been very difficult with HIPAA laws and things like that. So I'm wondering if you guys are doing anything similar at your institution  and how you've kind of come across and barriers you've had and how you fix those.  Yeah, thank you for that. One of the issues that we've come across, I would say our NICU has been a pioneer in using FaceTime and other devices to engage families.  And it was our nursing colleagues, actually, who had the most angst about it, mainly because they were worried about litigation and about all the stuff that goes along  with having your practice being monitored on a regular basis. And so that's part of why some of the things that have been done have not included audio feeds,  has just been a video feed. And even in our NICU, where we have the nanny cams, it's only on the isolette. It's not on the surroundings.  And some of the things that we have done is that we've given the nurses control to put it in, I forgot the name of the mode, but it's  like a silent mode if you want some privacy about something that you're doing. We've run into that with using FaceTime for family-centered  rounds, because we have a policy at our hospital that families cannot record without our knowledge about what's going on, not just in family-centered rounds,  but also in family meetings and so on and so forth. And so we had to do some adjustments to our policy to allow video conferencing on family-centered rounds.  So I don't know if that's helpful, but we have to think about all the stakeholders who it matters to the most. And for us, it was our nursing colleagues  who really brought up some important points about their own privacy and thinking about hospital-wide what our policies had to do to make changes to allow for it.  I should have just stayed up here. Our issue is more with, because we ended up using Skype and it was only allowed because it was in the research setting  and we got informed consent from the family since it's a non-secure web application. So we actually had great buy-in from our nurses. Our nurses had the best satisfaction scores  aside from the families. And I shockingly had pretty good buy-in from my physician colleagues as well, but it was more the upper levels of the hospital saying  this isn't HIPAA compliant. This could be hacked by whoever wants to hack it. I don't know why you would want that. But I had more issues from the upper levels  and less issues on the ground. So I didn't know if you guys had experience with that as well. So we're having issues with sustainability  because we can't continue to use the Skype interface. Yeah, we're just letting people use their own devices. We are too. Thank you.  And usually for us it's more so in pediatrics we have, it's usually two parents. So one parent is at the bedside and wants the other parent to participate.  So usually it's that parent calling their spouse or significant other. We haven't run into problems with that. I'm an adult intensivist pulmonologist  and I hate to think against what you're saying. You know, I think families know that you know what you know. But they really want to know are two things.  One, that you care, which we have to focus on. How do we deliver that concept to show that we care? And two, they want to know certain facts about the patient's care.  We do bedside rounds. But I'm against, you know, we have a 24-bed ICU. And if it takes an hour to an hour and a half to do 24 beds  and if we incorporate the family, I'm against that somewhat. I'm all in favor of having time to talk to the family one-on-one.  I think this has come about, this family-centered rounds has come about, it's sort of like a weed. It's growing because there's a lack of attention of the physician  or the nurse to talk to the family. So there's bad, you know, we're not doing our job perhaps. And that's why this is coming out as a solution.  And I really think our nurses, our therapists, our pharmacists, our nutritionists, they're joining us on rounds. And we need their input and their communication.  And that takes a lot of time. And to create that goal. And if we include the family who may not have all that information  and knowledge how to process that, that is going to take rounds even longer. And then we're delaying their ability to care for their patients because they're involved in our rounds.  And rounds have to be a fast and efficient form. Now, I also believe there's a difference between adults and pediatrics in neonatal ICU.  You know, my hat's to you for taking care of our little ones. That's a whole different ballgame. But I just don't want, I think we have to come back on rounds  and tell the family instead of including them on our rounds that we will come back one-on-one and sit down with them at our time  and not include the other personnel that are participating in our rounds. And I really think they, what we really need to determine is how do we show families that we care?  Thank you for that. I think you brought up lots of points. There's lots of things that are different between adults like you brought up and pediatrics and neonatology.  I will say the literature still supports that it still only increases rounds in adult medicine about a minute to two minutes as well.  And I think that that can be a big difference when you're rounding on a really big unit. You also struck on something that's really important is  that overall we're not communicating with families as well as we should or as well as we used to, and there are some gaps.  And families are feeling often that there's a lack of trust with providers. And one of the things that helps them to regain back some of this trust is knowing  that they are part of the team and they are included in all types of discussions. So a lot of families, actually family-centered rounds can help them gain some  of that trust back, and you're right. Having those bedside one-on-one conversations are so important and families value that most.  When we surveyed families in the pediatric ICU about how you wanted to be communicated with, the number one way that families said they wanted to be communicated  with was one-on-one with their provider. And then the second was family-centered rounds, and the last was sitting in a family conference.  And so there's definitely a lot of variables that are part of why there's reluctance to include families in family-centered rounds.  But I will tell you they want it, and I think that it also helps us to build trusting relationships with them. Thank you. I think we're just about out of time.  I'm not sure if you guys can hang out for a bit. Maybe you want to come up and speak, have a question from the speaker. But thank you all for coming.

Video Summary

In this video transcript, three speakers discuss the importance of family presence in rounds in the healthcare setting. They highlight the historical foundations of family-centered care in the ICU and emphasize the need for ongoing research and collaboration to improve this practice. The speakers discuss the benefits of involving families in rounds, including increased efficiency, better communication and coordination, and improved outcomes. They also address the challenges that nurses face in embracing family presence, such as heavy patient loads and medication administration. The speakers reference studies that have shown positive results in increasing nurse attendance on family-centered rounds and improving family engagement. They emphasize the need for physician buy-in and suggest strategies for engaging and empowering families, such as providing structured appointments and allowing families to determine their level of participation. Overall, the speakers stress the value of families as part of the care team and the unique perspectives they bring to the care process. They conclude that family-centered rounds should be seen as an additional means of involving families in the care process, complementing one-on-one communication.

Asset Subtitle

Patient and Family Support, Professional Development and Education, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Describe the positive effects of family presence in the ICU
Examine the controversies of family presence in the ICU
Explore the impact of family-centered care on family engagement scores

Historical Foundations of Family Presence in the ICU

Kathryn E. Roberts

Family Attendance in Rounds: Nursing Perspective

Andrea Kline-Tilford

Family Attendance in Rounds: Physician Perspective

Tessie W. October

Meta Tag

Content Type Presentation

Knowledge Area Patient and Family Support

Knowledge Area Professional Development and Education

Knowledge Level Foundational

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Patient and Family Communication

Tag Team Leadership

Year 2020

Keywords

family presence

rounds

healthcare setting

family-centered care

research

communication

nurses

challenges

studies

care team

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