Visitation in critical care: processes and outcomes of a performance improvement initiative

When family members became dissatisfied with a restrictive visiting policy in a combined coronary and medical intensive care unit, this situation was seen as an opportunity to better meet patient and family needs. A review of the literature indicated that open visitation policies enhance patient and family satisfaction, while a survey of patients, families, and health care team members revealed a desire for a more open visitation policy. Nursing staff, with input from other disciplines, developed and implemented a less restrictive visitation policy. Post-intervention surveys revealed higher patient and family satisfaction and a marked decrease in formal complaints.     

The post anesthesia care unit experience: a family-centered approach

The Post Anesthesia Care Unit (PACU) visitation program of Memorial Sloan-Kettering Cancer Center needed revision. The process was disorganized, visits were unescorted, and nurses and physicians were resistant. A committee was formed with the goal of developing a new unit philosophy and improving the overall process. Committee steps included reviewing the literature, educating staff about the benefits of visitation, empowering nurses to incorporate family visitation into patient care, and providing family education. As a result, staff attitudes changed, and nurses now contact the family within 90 minutes of the patient's arrival to the PACU to develop an individualized visitation plan. Morale is high, and nurses take pride in meeting the needs of patients and families.     

Nurses' perceptions of open visiting hours in neuroscience intensive care unit

A quality improvement project was undertaken by Neuro-ICU nurses to determine possible effects from open visitation. From a quality improvement perspective, nurses' concerns were investigated along with their perceptions about open visitation to determine a need for visitation policy revision. Vast variability in nurses' interpretation and implementation of individualized open visitation policy suggested a need for the following: staff education about the policy and its implementation, a review of the literature to determine the validity of concerns about deleterious physiologic effects on neuroscience patients from visitation, and improved communication among nurses about visitation.     

A visit to the intensive cares unit: a family-centered culture change to facilitate pediatric visitation in an adult intensive care unit

To guide family adjustment, an effort was made to facilitate pediatric visitation in an adult intensive care unit (ICU). Goals were to improve customer satisfaction and to raise staff comfort level with child visitation. After implementing an open visitation policy, concerns around pediatric visitation in the ICU remained. Fears centered on risks to both patient and child. Literature was reviewed before a book was written entitled A Visit to the ICU. It contained information about what a child visiting the ICU would see, hear, and feel when visiting a loved one. The book provided reassurance for caregivers and children, informing them about what to expect when visiting. The goal of the book was to provide caregivers with a framework for age-appropriate education. Staff education was provided on developmental stages, including a child's understandings of illness and death. Nursing interventions were reviewed and resources provided. A survey demonstrated that the book increased staff comfort level with children visiting the unit, was a positive tool for patients and families, and eased fears among children while helping to facilitate coping mechanisms. The article will describe the practice change of pediatric visitation in an ICU and how it could be applied to other critical care settings.     

Open visiting in adult intensive care units – A structured literature review

BackgroundOpen visitation in adult intensive care units report benefits such as reduced frequency and duration of deliriums, improved patient and family satisfaction, and reduced anxiety and depression of family members. ‘Being close’ is one of the most basic and important needs of family members of critically ill patients. Open visitation provides an increased opportunity of being at the bedside with the patient, however, it is not universally embraced by adult intensive care units worldwide.AimTo critically appraise the literature concerning open visitation in adult intensive care units.DesignA structured literature review.MethodThis review was guided by the methodology by Kable et al. (2012). Sixteen articles are included in the review.ResultsDespite the documented benefits, several challenges exist which hinder broad application of open visitation in adult intensive care units.ConclusionThis review acknowledged challenges faced in adopting an open visiting policy in adult intensive care units such as negative staff perceptions and attitudes; patient protection; family and cultural consideration, as well as organisational challenges. The lack of a clear and consistent definition of open visitation is problematic, and strategies are urgently needed to support staff to provide holistic patient- and family-centred care.     

Visitation in the intensive care unit: impact on infection prevention and control

Evidence-based practice has shown that open visitation in the intensive care setting positively impacts patient outcomes. However, many intensive care units continue to strictly limit visitation hours. One concern for nurses is that open visitation will expose their vulnerable patients to an increased risk of infection. This fear is unfounded in professional literature as well as in the experience of a busy intensive care unit in San Antonio, Texas. Keeping our patients safe from hospital-acquired infections requires vigilant attention to infection prevention procedures. Meanwhile, what may actually be bugging our patients is a health care culture that is based on tradition and is blind to the many benefits provided by a more liberal visitation policy rooted in patient-centered care.     

Open visitation policies and practices in US ICUs: can we ever get there?

Open visitation has been highly recommended by critical care groups but is not prevalent in practice. Here we discuss the present study on current visitation practices in US ICUs and discuss several factors affecting open visitation. We conclude with suggestions on achieving more liberal visitation practices.In a previous issue of Critical Care, Liu and colleagues embark upon a timely and important topic: visitation practices in US ICUs [1].There are many benefits to open visitation. Patients feel supported [2] and safe [3]. Families are more satisfied with care and are less anxious [4]. Healthcare providers have increased opportunities for communication and teaching [2]. Because of these benefits, open and unrestricted visitation in ICUs has been recommended by critical care groups [5,6]. However, Liu and colleagues report that almost all US ICUs (90%) have restrictive visitation policies, and most (62%) have three or more restrictions. What is disconcerting is that these findings are not all that different from those reported in 2007, where only 32% of ICUs had open visitation [7]. Even this statistic is misleading, because ''open'' referred only to the hours of visitation, and most ICUs considered open had restrictions on age and the number of visitors [7]. Liu and colleagues'' findings are also consistent with those from other countries where very few, if any, ICUs have open visitation policies [8,9]. With all of the evidence guiding practice toward open visitation, why is it that most ICUs continue to have restrictions on visitation? There are several factors to be considered before ICUs truly embrace open visitation.One factor is the ICU patient. Open visitation has been studied from the perspective of the family and the healthcare provider, but very few studies have focused on the patient''s perspective. Because ICU patients are often unable to communicate their preferences about visitation, they are often excluded from research studies. However, Olsen and colleagues interviewed 11 ICU patients to gain their perspective on visitation [10]. These patients stated that they felt supported when their families were present and were in favor of flexible visitation. Yet most patients wanted some limitations, such as having only close family members visit. In addition, these patients felt stressed when trying to communicate with visitors and when thinking about how upsetting this experience was for their families [10]. Recently, Hardin and colleagues surveyed 122 ICU patients on their satisfaction with unrestricted visiting hours [11]. Their results support those of Olsen and colleagues, since most patients wanted some restrictions and control over visitation. These two studies on the patient''s perspective indicate that the patient''s voice needs to be heard when developing visitation policies.Another factor is the potential contributions of visiting ICU family members to the well-being of their loved ones. Interviews of 25 family members of 24 high risk of dying ICU patients showed that families took on certain roles while in the ICU and that they were physically and actively present in their loved ones'' care [12]. These families reported that they were physically and actively present in their loved ones'' care. Families'' contributions included protecting the patient, facilitating information, providing necessary patient history, comforting and motivating the patient, and performing caregiving activities. As a result, families believed the patient felt safer and more supported if they were present. Others have found that families can contribute to patient care by keeping ICU diaries for the patient [13]. In families that kept diaries, researchers reported significantly lower post-traumatic stress symptoms in both patients and family members 12 months after the ICU stay [13]. Families can also contribute to patient care by participating in patient rounds. Investigators assessing this approach reported improved family satisfaction with communication and decision-making, both of which are important needs for families [14]. Families have much to offer, and allowing them open visitation could help them fulfill their roles, contribute to patient care, and decrease patient and family symptoms.One more factor is the healthcare provider. In a study comparing healthcare providers'' beliefs and attitudes toward open visitation, researchers found that nurses were generally not in favor of it [15]. Nurses feared losing control of their ICU room and felt that visits did not offer more comfort and support to the family. They also felt that open visitation hindered patient rest, infringed on patient privacy, and was an impediment to the nurses doing their job [15]. In addition, there is a great deal of inconsistency among healthcare providers in the level of comfort they have in communicating with families. For example, those who feel more comfortable working with families may favor open visitation, whereas those who do not may want stricter visitation policies. Liu and colleagues found this lack of consistency to be the case, with more restrictions in the Northeast and fewer restrictions in the Midwest and smaller hospitals [1]. This lack of consistency, along with varying beliefs and attitudes toward visitation, can lead to confusion and resentment to all involved (patient, family and healthcare provider) and may be another factor as to why open visitation policies in ICUs continue to be elusive.So how do ICUs embrace open visitation? First, it should be understood that open visitation is not a one-size-fits-all philosophy. Second, it should be clarified that open visitation does not mean a free-for-all, with visitors being on the unit whenever they like. Third, it is important to understand that addressing visitation is a complex process that means patient interests are accounted for, clinicians have improved communication skills, and families are supported and prepared for their visits. Fourth, changing the terms ''open'' and ''unrestricted'' to ''flexible'' and ''liberal'' could help alleviate some of the barriers that healthcare providers have toward open visitation. Finally, perhaps each ICU will need to have an individualized approach to open visitation policies that meet the needs of the patient, the family, and the healthcare provider. However ICUs choose to embrace open visitation, it needs to happen.     

Visiting hospitalized patients

Visiting policies in acute care institutions affect patients and families. The study sought to answer these questions: What are current hospital visiting policies and accompanying provisions for families? How are nurses implementing these policies? A questionnaire was developed, and reliability and content validity were established. The questionnaire was mailed to a randomly selected, stratified sample of 125 approved hospitals in 10 US states, with a 40% return rate. Consent and anonymity were explained in an accompanying covering letter. Results indicated that there was a wide range of general hospital visiting hours. Limitations on general visiting hours were primarily due to hospital policy (age, children, number of visitors) and nursing judgement (visitor illness, length of visit). General visiting hours and intensive care area visiting hours for paediatric patients were more extensive than for adult patients. Factors which influenced exceptions to visitation policies in intensive care areas focused on patient acuity and patient needs. Recovery room visiting was limited. If the patient was in a private room, visiting hours and provisions for family members were extensive. Provisions for family members of intensive care patients were minimal. Nursing judgement significantly influenced implementation of. visitation policies.     

成人ICU弹性探视制度面临挑战质性研究的Meta整合

目的系统评价和整合国内外成人ICU弹性探视制度面临的挑战,为促进弹性探视制度的有效实施提供科学依据。方法计算机检索Cochrane Library、Joanna Briggs Institute循证卫生保健国际合作中心图书馆、PubMed、EMbase、EBSCO、Scopus、Web of Science核心合集、CINAHL、中国知网、万方数据知识服务平台关于成人ICU在应用弹性探视制度中的体验、挑战或障碍等质性研究类文献,检索时限均为建库至2019年12月。采用Joanna Briggs Institute循证卫生保健中心质性研究质量评价标准(2016)评价文献质量,采用Meta整合的方法进行结果整合。结果共纳入4篇文献,提炼35个研究结果,将相似结果组合形成7个新类别,进一步综合得出4个整合结果,分别为医生或护士的负面感知和态度、不利于患者保护、对家属探视认知或文化信仰的考量、对组织的挑战。结论成人ICU弹性探视制度面临诸多挑战,管理者可提供整体的以患者及家庭为中心的护理策略,创建健康的工作环境,优化ICU物理环境设计,促进弹性探视制度的临床实践。     

Aromatherapy Blend for Postoperative Nausea in Ambulatory Surgery Patients

PurposePostoperative nausea (PON) is one of the most common undesirable outcomes after surgery and increases patient dissatisfaction, hospital costs, and risk for postoperative complications. This quality-improvement project implemented and evaluated the effect of aromatherapy on nausea in adult postoperative patients.DesignQuality improvement project evaluating the inhalation of a blend of essential oils through an individual stick via an aroma stick.MethodsThis quality-improvement project was implemented in a postanesthesia care unit (PACU) in the Northeastern United States that averages 300 adult patients per month. Over the course of 12 weeks in the Fall of 2019, the project sample included all PACU registered nurses and patients with PON without allergies to inhalation agents or nasal surgery.FindingsOne hundred percent of PACU registered nurses (n = 20) were educated and demonstrated competence in the aromatherapy intervention; 70.6% (n = 36) of patients with PON used an aroma stick for PON treatment. Of the patients receiving the aroma stick for PON, 94.4% (n = 34) had improved PON scores.ConclusionsAromatherapy is an effective nonpharmacological treatment in reducing PON score for patients recovering from surgery. These results offer support for nursing practice to use aromatherapy as an additional method to enhance patient experience, improve outcomes, and reduce cost in recovery rooms.     

Postoperative Discomfort (Other than Pain) – A Neglected Feature of Postanesthesia Patient Care

OBJECTIVE: Patients may experience various kinds of discomfort other than pain during the immediate period following surgery and anesthesia. These complaints may not be dealt with, especially when they are shadowed by the more pressing need to alleviate pain. The issue of discomfort in the setting of an adult post anesthesia care unit (PACU) has not been adequately addressed. We assessed the extent of unreported distressing or unpleasant events among patients who had undergone general surgery or orthopedic procedures under standard general anesthesia and their recall 24 h afterwards. METHODS: As customary, the PACU staff recorded vital signs, and assessed pain level; if pain score was 90% recalled 24 h after surgery having had postoperative discomfort. PACU staff needs to inquire for and attempt reducing such events.     

Implementation and sustainment strategies for open visitation in the intensive care unit: A multicentre qualitative study

ObjectiveOpen visitation in adult intensive care units has been associated with improved family and patient outcomes. However, worldwide adoption of this practice has been slow and reasons for this are unclear. This study documents barriers and strategies for implementing and sustaining open visitation in adult intensive care units in the United States experienced by nursing leadership.Research designQualitative approach using grounded theory.ParticipantsNurse leaders in adult intensive care units with open visitation.SettingMagnet® or Pathway to Excellence® designated hospitals in the United States.MethodsSemi structured interviews were conducted with 19 nurse leaders from 15 geographically dispersed hospitals. Interviews were recorded, transcribed and imported into Atlas.ti qualitative software for analysis. Grounded theory constant comparison analysis was used for coding and category development.FindingsThe analysis revealed three barriers; nursing attitudes and clinical and nonclinical barriers. Strategies to overcome these barriers were empathy, evidence-based practice, models of care, shared governance, nurse discretion, security and family spaces.ConclusionIntensive care nursing leadership experienced distinct barriers and strategies during pre-implementation, implementation and sustainment of open visitation. Other nursing leaders interested in open visitation can use these findings as they plan this transition in their intensive care units.     

What can the postanesthesiacare unit manager do to decrease costs in the postanesthesia care unit?

The economic structure of the PACU dictates whether a cost-reducing intervention (e.g., reducing the length of time patients stay in the PACU) is likely to decrease hospital costs. Cost-reducing interventions, such as changes in medical practice patterns (e.g., to reduce PACU length of stay), only impact variable costs. How PACU nurses are paid (e.g., salaried v hourly) affects which strategies to decrease PACU staffing costs will actually save money. For example, decreases in PACU labor costs resulting from increases in the number of patients that bypass the PACU vary depending on how the staff is compensated. The choice of anesthetic drugs and the elimination of low morbidity side effects of anesthesia, such as postoperative nausea, are likely to have little effect on the peak numbers of patients in a PACU and PACU staffing costs. Because the major determinant of labor productivity in the PACU is hour-to-hour and day-to-day variability in the timing of admissions from the operating room, a more even inflow of patients into the PACU could be attained by appropriate sequencing of cases in the operating room suite (e.g., have long cases scheduled at the beginning of the day). However, this mathematically proven solution may not be desirable. Surgeons, for example, may not want to lose control over the order of their cases. Guidelines for analysis of past daily peak numbers of patients are provided that will provide data to predict the minimum adequate number of nurses needed. Though many managers already do this manually on an ad hoc basis statistical methods summarized in this article may increase the accuracy.     

Safety of a Novel Obstructive Sleep Apnea Triage Tool for Postoperative Orthopedic Surgery Patients

PurposeThe purpose of this quality improvement project is to provide a tool for effective and safe triage of postoperative patients in the postanesthesia care unit with known or suspected obstructive sleep apnea (OSA) at an academic orthopedic hospital in New York City.DesignThe structure of this project was observational after implementation of a novel OSA triage tool.MethodsResults were reported from a single center experience in a hospital where there was no existing standard assessment tool consistently used to triage patients with either known or suspected OSA in the postoperative period. Adult patients who underwent orthopedic surgery between October 2018 and February 2020 and who had a known or suspected history of OSA were included. After admission to the postanesthesia care unit (PACU) and upon meeting their modified Aldrete criteria or after 2 hours had elapsed, the PACU primary provider used the OSA triage tool to assess whether the patient had a high or low risk of respiratory deterioration after discharge from the PACU related to OSA. Patients without high-risk criteria were discharged from the PACU to a medical/surgical unit. For patients with high-risk criteria, the PACU provider requested critical care consultation to determine each patient's appropriate hospital disposition upon PACU discharge.FindingsOver the course of the study period, 216 patients were evaluated using the OSA triage tool: 53.2% of the cohort was male, median BMI was 36.3 kg/m², and 80.1% had a prior diagnosis of obstructive sleep apnea. Patients underwent a variety of orthopedic surgeries with 23.6% having undergone hip surgery, 51.4% knee surgery, 13.4% spine surgery, 9.7% shoulder surgery, and 1.9% foot or ankle surgery. Notably, with the use of this tool, only 12.5% of patients met criteria for critical care consult and 91.7% were admitted to the floor from the PACU. Rapid response for respiratory complications were not observed in any of the patients. There were only three patients who required critical care evaluation after PACU discharge. An anonymous survey completed by PACU nurse practitioners and anesthesiologists revealed a 96.8% self-reported satisfaction with OSA triage tool.ConclusionWe demonstrated that use of a OSA triage tool in the single-center orthopedic PACU at NYULH is potentially a safe and effective method of triaging patients with known or suspected OSA to acute care beds versus higher levels of care.     

Implementing Nurse Home Visitation Programs

Nurse home visitation has been an important component of public health for over 100 years. Recent reports of large clinical trials have provided a convincing body of evidence of the cost-effectiveness of home visitation. The findings from these studies have helped to renew policy interest in nurse home visitation as a means of improving health and quality of life for low-income families. Reimplementing home visitation on a large scale, however, will require using nurses with little or no home-visiting experience. Sponsoring organizations must delegate, and nurses from hospitals or clinics must accept, responsibility for both increased autonomy and discretion of home visitors. Case study analysis of observational and interview data from the implementation of a large demonstration home visitation program carried out in a health department in a mid-South city from 1989 to 1994 provides evidence that the bottom-up perspective of Hanf and Toonen (1983) best describes how such programs can be put in place. Nurses with little community experience were able to create appropriate strategies to help families achieve the broad program goals in the context of resource constraints associated with a poverty-level lifestyle and the existing health and human service system. Furthermore, nurses were able to establish an organizational culture and job structure in a city/county health department to support their work.     

Family visitation in the PACU, 1984-2006.

Family visitation in postanesthesia care remains a controversial issue in North American hospitals. Historically, PACUs have been a closed and restricted area to the general public. Over the past 20 years, a growing body of nursing research has emerged challenging the restrictive practices of excluding family visitation in the immediate postoperative period. Because of the inconsistencies and gaps between current clinical practice and research, a review and analysis of past and present family visitation literature was conducted. Findings indicate that a further study of beliefs and workplace culture can contribute to a better understanding of impeding factors on a much needed change in policy.     

Handover Patterns in the PACU: A Review of the Literature

PurposeCurrently, there is no standardized handover pattern for patients undergoing general anesthesia when being transferred to the postanesthesia care unit (PACU).DesignA review of the literature.MethodsIn this study, a review of the literature was conducted to analyze the PACU handover status, factors for poor handover, and commonly used handover patterns.FindingsImportant handover information was often omitted during the handover of PACU patients, and there were many factors influencing postoperative patient handover quality. This study analyzed and compared several commonly used handover patterns for patients. Among these, the Situation-Background-Assessment-Recommendation tool is relatively mature. However, there is currently no unified standardized patient handover pattern, and the validity and applicability of tools still need to be verified.ConclusionsPACU is an important place for the recovery of surgical patients. Anesthesia providers need to provide PACU nurses with complete and comprehensive postoperative handover information. A standardized handover model for clinical nurses is needed to improve patient safety management and work efficiency.     

麻醉恢复室入室护理流程的应用

目的探讨麻醉恢复室(post-anesthesia care unit,PACU)入室护理流程的临床实践效果。方法建立PACU入室护理流程,内容包括连接呼吸机、连接监护仪、管道交接、皮肤交接等流程和对PACU护士进行培训、考核。结果流程应用前,术后患者入室护理时间从7.0 min降至流程应用后4.0 min,无1例发生护理风险及不良事件。结论 PACU入室护理流程的应用提高了护理质量,加强了患者安全。     

Comparison of an intraoperative infusion of dexmedetomidine or remifentanil on perioperative haemodynamics, hypnosis and sedation, and postoperative pain control

This prospective, randomized, double-blind study compared the effects of dexmedetomidine and remifentanil on haemodynamic stability, sedation and postoperative pain control in the postanaesthetic care unit (PACU). Fifty consecutive patients scheduled for total laparoscopic hysterectomy were randomly assigned to receive infusions of either dexmedetomidine (1 μg/kg) i.v. over 10 min followed by 0.2 - 0.7 μg/kg per h continuous i.v. infusion or remifentanil (0.8 - 1.2 μg/kg) i.v. over 1 min followed by 0.05 - 0.1 μg/kg i.v. per min, starting at the end of surgery to the time in the PACU. Modified observer's assessment of alertness scores were significantly lower in the dexmedetomidine group than in the remifentanil group at 0, 5 and 10 min after arrival in the PACU. Blood pressure and heart rate in the dexmedetomidine group were significantly lower than that recorded in the remifentanil group in the PACU. Dexmedetomidine, at the doses used in this study, had a significant advantage over remifentanil in terms of postoperative haemodynamic stability.     

Quality Improvement Initiative to Improve Postoperative Pain with a Clinical Pathway and Nursing Education Program

Background and AimsWe created a multicomponent intervention to improve pain management in the immediate postoperative period with the goal of improving the quality of patient recovery.DesignA multicomponent intervention to improve pain management in the immediate postoperative period with the goal of improving the quality of patient recovery.SettingsPain management education of postanesthesia recovery room nurses through a practical intervention has the potential to improve patient pain experience, especially in those with a history of opioid tolerance.Participants/SubjectsPostanesthesia recovery nurses/postanesthesia patients.MethodsThe intervention included two components: a clinical pain pathway on multimodal analgesia for both opioid-naïve and opioid-tolerant patients undergoing surgery and an educational program on pain management for frontline clinical nurses in the postanesthesia care unit (PACU). We measured the intervention's impact on time to pain relief, PACU length of stay, and patient satisfaction with pain management, as measured by self-report.ResultsPatient PACU surveys indicated a decrease in the percent of patients with opioid tolerance who required more than 60 minutes to achieve adequate pain relief (from 32.7% preintervention to 21.3% postintervention). Additionally, after the intervention, the average time from a patient's PACU arrival to his or her discharge criteria being met decreased by 53 minutes and PACU stay prolongation as a result of uncontrolled pain for opioid-tolerant patients decreased from 45.2% to 25.7%. The sample size was underpowered to perform statistical analysis of this improvement.ConclusionsAfter the combined intervention of a clinical pain pathway and interactive teaching workshop, we noted shortened PACU length of stay, reduced time to reach pain control, and improved overall patient satisfaction. Although we could not determine statistical significance, our findings suggest improved management of acute postoperative pain, especially for patients who are opioid tolerant. Because of the paucity of data, we were not able to conduct the analysis needed to evaluate quality improvement projects, as per SQUIRE 2.0. could be adopted by any institution.