icu visitationthe evidence is out there presentation objectives

ICU VISITATIONICU VISITATION……THE EVIDENCE IS OUT THERETHE EVIDENCE IS OUT THERE

Theresa Tomlinson RN, BSN

York Hospital

Open Heart Intensive Care Unit

Presentation ObjectivesPresentation ObjectivesPresentation ObjectivesPresentation ObjectivesPresentation ObjectivesPresentation ObjectivesPresentation ObjectivesPresentation Objectives

1. Define the practice issue regarding ICU visitation

2. State the EBP question

3. Describe the EBP process used by the ICU workgroup

4. List three EBP recommendations for implementing open

visitation in the ICU

The Johns Hopkins Nursing EvidenceThe Johns Hopkins Nursing EvidenceThe Johns Hopkins Nursing EvidenceThe Johns Hopkins Nursing Evidence----Based Practice Based Practice Based Practice Based Practice

Model and GuidelinesModel and GuidelinesModel and GuidelinesModel and Guidelines

The Johns Hopkins Nursing EvidenceThe Johns Hopkins Nursing EvidenceThe Johns Hopkins Nursing EvidenceThe Johns Hopkins Nursing Evidence----Based Practice Based Practice Based Practice Based Practice

Model and GuidelinesModel and GuidelinesModel and GuidelinesModel and GuidelinesThe PICOThe PICOThe PICOThe PICOThe PICOThe PICOThe PICOThe PICO QUESTIONQUESTIONQUESTIONQUESTIONQUESTIONQUESTIONQUESTIONQUESTION

Patient, Population, Problem

Intervention

Comparison with another variable

Outcome

PP

II

CC

O

The Patient, Population and ProblemThe Patient, Population and ProblemThe Patient, Population and ProblemThe Patient, Population and ProblemThe Patient, Population and ProblemThe Patient, Population and ProblemThe Patient, Population and ProblemThe Patient, Population and Problem

PPPPatient Adult ICU patients at York Hospital

PPPPopulation Family, visitors, and ICU staff

PPPProblem Inconsistent implementation of

visiting hours among and within the

ICUs.

Background and Current PracticeBackground and Current PracticeBackground and Current PracticeBackground and Current PracticeBackground and Current PracticeBackground and Current PracticeBackground and Current PracticeBackground and Current Practice

Why do we do that?Why do we do that?Why do we do that?Why do we do that?Why do we do that?Why do we do that?Why do we do that?Why do we do that? The InterventionThe InterventionThe InterventionThe Intervention

More structure to the visitation policy

The ComparisonThe ComparisonThe ComparisonThe Comparison

Current visitation policy at York Hospital

The OutcomeThe OutcomeThe OutcomeThe Outcome

Promotes patient safety and patient, family

& staff satisfaction

Our Current PracticeOur Current PracticeOur Current PracticeOur Current PracticeOur Current PracticeOur Current PracticeOur Current PracticeOur Current Practice

OHICUOHICUOHICUOHICU

0800 rounds

11am - 8pm

15 minutes post-op

CCUCCUCCUCCU 11am - 8pm

MSICUMSICUMSICUMSICU liberal visitation

TSICUTSICUTSICUTSICU

10 am - 12 pm

2 pm – 4 pm

6 pm – 8 pm

MTCUMTCUMTCUMTCU liberal visitation

STCUSTCUSTCUSTCU 11 am – 8 pm

EBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTION

Is a more structured visitation regimen in the ICU

more conducive to patient safety and rest, and

nurse, patient and family satisfaction than our

current ICU visitation policy?

The ICU Visitation WorkgroupThe ICU Visitation WorkgroupThe ICU Visitation WorkgroupThe ICU Visitation WorkgroupThe ICU Visitation WorkgroupThe ICU Visitation WorkgroupThe ICU Visitation WorkgroupThe ICU Visitation Workgroup

All ICUs in York Hospital were represented.

OHICUOHICUOHICUOHICU MSICUMSICUMSICUMSICU CCUCCUCCUCCU TSICUTSICUTSICUTSICU MTCUMTCUMTCUMTCU STCUSTCUSTCUSTCU

Stephanie

Church

Doris

Lentz

Margie

Lane

Cheryl

Churilla

Renee

Pruner

Maria Smith

Becky

Senft

Allison

Taylor

Collecting the EvidenceCollecting the EvidenceCollecting the EvidenceCollecting the EvidenceCollecting the EvidenceCollecting the EvidenceCollecting the EvidenceCollecting the Evidence

DatabasesDatabasesDatabasesDatabases

Pub Med , CINAHL , Pub Med , CINAHL , Pub Med , CINAHL , Pub Med , CINAHL ,

Cochran , Google Scholar,Cochran , Google Scholar,Cochran , Google Scholar,Cochran , Google Scholar,

reference lists, professionalreference lists, professionalreference lists, professionalreference lists, professional

organizationsorganizationsorganizationsorganizations

Key WordsKey WordsKey WordsKey WordsICU visitation, critical care ICU visitation, critical care ICU visitation, critical care ICU visitation, critical care

visitation, effects of visitation on visitation, effects of visitation on visitation, effects of visitation on visitation, effects of visitation on

patients, family visitation, and ICUpatients, family visitation, and ICUpatients, family visitation, and ICUpatients, family visitation, and ICU

Search ParametersSearch ParametersSearch ParametersSearch Parameters English language, articles from English language, articles from English language, articles from English language, articles from

1995199519951995----2011201120112011

# Articles # Articles # Articles # Articles 41 articles reviewed41 articles reviewed41 articles reviewed41 articles reviewed

7 articles discarded7 articles discarded7 articles discarded7 articles discarded

Evidence LevelEvidence LevelEvidence LevelEvidence Level Number of ArticlesNumber of ArticlesNumber of ArticlesNumber of Articles

I: Experimental 0

II: Quasi-experimental 1

III: Non-experimental/Descriptive 9

IV: Opinion of nationally recognized experts based on

scientific evidence6

V: Opinion of nationally recognized experts based on

experiential evidence.18

Levels of EvidenceLevels of EvidenceLevels of EvidenceLevels of EvidenceLevels of EvidenceLevels of EvidenceLevels of EvidenceLevels of Evidence

**41 articles reviewed. 7 articles were “C” quality and not used for

recommendations.

Definition of Open VisitationDefinition of Open VisitationDefinition of Open VisitationDefinition of Open VisitationDefinition of Open VisitationDefinition of Open VisitationDefinition of Open VisitationDefinition of Open Visitation

� Variable

�24/7

�Closed during resuscitation or codes

�Closed during change of shift report

�Closed during rounds

EVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTS

PATIENT

�Patients prefer to be given the

choice for visiting preferences(Carroll, 2009)

�Visiting does not cause

detrimental physiological changes

(HR, BP, rhythm, ICP, stress

hormones) (Fumigalli, 2006)

�Patients prefer to have family

near for support (Cypress, 2010)


FAMILY

1. Close proximity to the patient

2. Honest communication

3. To be informed

4. Care and support from staff

(Molter, 1976), (Gavaghn & Carroll, 2002)


NURSING

1. Visiting policies are enforced to

varying degrees in ICUs

2. Resistance to open visitation

- patient safety

- interruptions/delays in

patient care

- space

-HIPAA

(Lee et al., 2007), (Livesay et al., 2005),

(Kirchoff & Dahl, 2006)

Support for Open VisitationSupport for Open VisitationSupport for Open VisitationSupport for Open VisitationSupport for Open VisitationSupport for Open VisitationSupport for Open VisitationSupport for Open Visitation

1. Institute of Medicine

2. Centers for Medicare and Medicaid

3. Institute for Patient and Family-Centered Care

4. The Joint Commission: Advancing Effective

Communication, Cultural Competence, and Patient- and

Family-Centered Care: A Roadmap for Hospitals

5. Institute for Healthcare Improvement

6. Relationship-Based Care Initiatives

EBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTION

Is structured visitation in the ICU setting more

effective than York Hospital’s current policy in

promoting patient safety and rest, and nurse,

patient, and family satisfaction?

Practice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice Recommendations

Evidence shows that open visitation in

ICUs is safe to the patient and preferred by families and patients over structured

visitation policies.


1. Planning

� It’s more than revising a policy

�Implementation of open visitation is an ongoing

process

- changes will happen along the way

�The process is lengthy

- Use a trial period


2. Communication

�Involve all stakeholders in implementation

(patient & family, ICU staff, security, leadership,

RRT, PT, physician, risk mgmt…)

- Patient Advisory Councils

- Nursing Committees

- ICU CET

- staff surveys

�Use bulletin boards, pamphlets, signage


3. Education

�Disseminate the information

�Educate at many levels within the organization

�Incorporate education into required learning for

staff

�Use many forms of education: presentations,

posters, pamphlets for patients

- Patient Educator/Liason


4. Broad Policy Recommendations

� The patient should dictate visitation preferences

�Utilize a spokesperson to maintain HIPAA

�Create a written visitation policy

�Safety and security of patient and staff should

never be compromised.


5. Expect Challenges

� Open visitation is a culture change for most ICUs

� Nursing will resist

- Education and communication will facilitate

change

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Berwick, D. M., & Kotagal, M. (2004). Restricted visiting hours in ICUs: Time to change. Journal of the American Medical

Association, 292, 736-737. doi: 10.1001/jama.292.6.736

Brilli, R. J. (2004). Restrictions on family presence in the ICU [Peer commentary on the journal article “Restricted visiting hours in

ICUs: Time to change” by D. M. Berwick]. Journal of the American Medical Association, 292(22), 2721. doi:

10.001/jama.292.22.2721-b

Carroll, D. L., & Gonzalez, C. E. (2009). Visiting preferences of cardiovascular patients. Progress in Cardiovascular Nursing,

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Cypress, B. S. (2010). The intensive care unit: Experiences of patients, families, and their nurses. Dimensions of Critical Care

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