ICU VISITATION…THE EVIDENCE IS OUT THERE …2011\Tomlinson.pdf · ICU VISITATION…THE EVIDENCE IS OUT THERE Theresa Tomlinson RN, BSN York Hospital Open Heart Intensive Care Unit

ICU VISITATIONICU VISITATIONTHE 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 reviewed7 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 Hospitals 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

Its 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

ReferencesReferencesReferencesReferences

Berti, D., Ferdinande, P., & Moons, P. (2007). Beliefs and attitudes of intensive care nurses toward visits and open visiting

policy. Intensive Care Medicine, 33, 1060-1065. doi: 10.1007/s00134-007-0599-x

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,

149-154. Retrieved from http://www.ebscohost.com

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

Nursing, 29, 94-101. Retrieved from http://www.ebscohost.comDamboise, C., & Cordin, S. (2003). Family-centered critical care: How one unit implemented a plan. American Journal of

Nursing, 103, 56AA-56EE. Retrieved from http://www.nursingcenter.com

Davidson, J. E., Powers, K., Hedayat, K., Tieszen, M., Kon, A. A., Shepard, E., ... Levy, M. (2007). Clinical practice

guidelines for support of the family in the patient-centered intensive care unit: American college of

critical care medicine task-force 2004-2005. Critical Care Medicine, 35, 605-616. doi:

10.1097/01.CCM.0000254067.14607.EB

Ellis, K. (1988). Asking visitors to leave: When and how to do it. Nursing88, 64. Retrieved from http://www.ebscohost.com

Eriksson, T., & Bergbom, I. (2007). Visits to intensive care unit patients-frequency, duration and impact on outcome. Nursing in

Critical Care, 12, 20-26. Retrieved from http://www.ebscohost.com

Farrell, M. E., Joseph, D. H., & Schwartz-Barcott, D. (2005). Visiting hours in the ICU: Finding the balance among patient,

visitor and staff needs. Nursing Forum, 40, 18-28. Retrieved from http://www.ebscohost.comFontaine, D. K., Briggs, L. P., & Pope-Smith, B. (2001). Designing humanistic critical care environments. Critical Care Nursing

Quarterly, 24, 21-34. Retrieved from http://www.ebscohost.com

Fumigalli, S., Boncinelli, L., Lo Nostro, A., Valoti, P., Baldereschi, G., Di Bari, M., ... Machionni, N. (2006). Reduced cardiocirculatory

complications with unrestrictive visiting policy in an intensive care unit: Results from a pilot, randomized trial. Circulation,

113, 946-952. Retrieved from http://www.circahajournals.org

Garrouste-Orgeas, M., Philippart, F., Timsit, J. F., Diaw, F., Willems, V., Tabah, A., ... Carlet, J. (2008). Perceptions of a 24-

hour visiting policy in the intensive care unit. Critical Care Medicine, 36, 30-35. doi:

10.1097/01.CCM.0000295310.29099.F8


Gavaghan, S. R., & Carroll, D. L. (2002). Families of critically ill patients and the effect of nursing interventions. Dimensions of

Critical Care Nursing, 21, 64-71. Retrieved from http://www.ebscohost.com

Giannini, A. (2010). The open ICU: not just a question of time [Peer commentary on the journal article Restricting visiting in ICUs

is neither caring, compassionate, nor necessary by D. M. Berwick & M. Kotagal]. Minerva Anestesiologica, 76(2), 88-9.

Retrieved from http://www.ebscohost.com

Hardin, S. R., Bernhardt-Tindal, K., Hart, A., & Henson, A. (2011). Ciritical-care visitation: The patients perspective. Dimensions of

Critical Care Nursing, 53-61. doi: 10.1097/DCC.0b013e3181fd03a0

Heitman, L., & McClard, C. (2009). Innovative solutions-The art of improvisation: Patient and family preferences for visitation in

critical care. Dimensions of Critical Care Nursing, 28, 110-11. Retrieved from http://www.ebscohost.com

Henneman, E. A., & Cardin, S. (2002). Family-centered critical care: A practical approach to making it happen. Critical Care Nurse,

22, 12-19. Retrieved from http://www.google.comHunter, J. D., Goddard, C., Rothwell, M., Ketharaju, S., & Cooper, H. (2010). A survey of intensive care unit visiting policies in the

United Kingdom. Anaesthesia, 1-5. doi: 10.1111/j.1365-2044.2010.06506.x

Institute for Patient-and Family-Centered Care. (2010). Changing hospital visiting policies and practices: supporting family

presence and participation (Executive Summary). Bethesda, MD: Author.

Kirchoff, K. T., & Dahl, N. (2006). American Association of Critical-Care Nurses national survey of facilities and units providing

critical care. American Journal of Critical Care, 15, 13-28. Retrieved from http://www.aacn.org

Kishbaugh, L. (2004). Second times the charm for open-visiting effort. Healthcare Benchmarks and Quality Improvement, 41-3.


Kleinpell, R. M. (2008). Visiting hours in the intensive care unit: More evidence that open visitation is beneficial. Critical Care

Medicine, 36, 334-335. doi: 10.1097/.01.CCM.

Latour, J. M. (2007). Families in the ICU: Do we truly consider their needs, experiences and satisfaction?. Nursing in Critical Care, 12, 173-4. Retrieved from http://www.ebscohost.com

Lee, M. D., Freidenberg, A. S., Mukpo, D. H., Conray, K., Palmisciano, A., & Levy, M. M. (2007). Visiting hours policies in New

England intensive care units: Strategies for improvement. Critical Care Medicine, 35, 497-501. doi:

10.1097/.01.CCM.0000254338.87182.AC

Livesay, S., Mokracek, M., Sebastian, S., & Hickey, J. V. (2005). Nurses perceptions of open visiting hours in neuroscience

intensive care unit. Journal of Nursing Care Quarterly, 20, 182-189. Retrieved from http://www.ebscohost.com

Marco, L., Bermejillo, I., Garayalde, N., Sarrate, I., Margall, M. A., & Asiain, M. C. (2006). Intensive care nurses beliefs and

attitudes towards the effect of open visiting on patients, family and nurses. Nursing in Critical Care, 11, 33-41.



Obama, B. (2010). Hospital visitation (Presidential Memorandum). Retrieved from http://www.whitehouse.gov/the-press-

office/presidential-memorandum-hospital-visitation: http://www.whitehouse.gov

Petterson, M. (2005). Process helped gain acceptance for open visitation hours. Critical Care Nurse, 25, 71-3. Retrieved from

http://ccn.aacnjournals.org

Plowright, C. (2007). Visiting practices in hospitals. Nursing in Critical Care, 12, 61-63. doi: Retrieved from

http://www.ebscohost.com

Ramsey, P., Cathelyn, J., Gugliotta, B., & Glenn, L. L. (2000). Restricted versus open ICUs. Nursing Management, 42-4.

Retrieved from http://www.nursingmanagement.com

Rogness, B., Henrickson, K., Kohout, M., Smith, A., Brennan, L., Greene, M. T., ... Popies, J. (2008). Flexible ICU visitation hours

improve family involvement in care. Retrieved from http:ww.IHI.org

Roland, P., Russell, J., Richards, K. C., & Sullivan, S. C. (2001). Visitation in critical care: Processes and outcomes of a performance improvement initiative. Journal of Nursing Care Quarterly, 15, 18-26. Retrieved from

http://www.ebscohost.com

Rollins, G. (2005). Open all hours. Retrieved from http://www.H&HN.com

Scanlan, C. F. (2010, December 15). Final CMS rules on patient visitation rights (Memo). Retrieved from The Hospital &

Healthsystem Association of Pennsylvania: http://www.haponline.org

Sims, J. M., & Miracle, V. A. (2006). A look at critical care visitation. Dimensions of Critical Care Nursing, 25, 175-181. Retrieved

from http://www.ebscohost.com

The Hospital & Healthsystem Association of Pennsylvania. (2010). Important provisions in the final rule (Fact Sheet). Retrieved from

The Hospital & Healthsystem Association of Pennsylvania: http://www.haponline.org

To comply with new TJC standards, toss out restictive visitation policies. (2010). Patient Education Management, 17,

121-123. Retrieved from http://www.ahcmedia.com/online.html.Van Horn, E. R., & Katz, D. (2007). Promotion of family integrity in the acute care setting. Dimensions of Critical Care Nursing, 26,

101-7. Retrieved from http://www.ebscohost.com

Vandijck, D. M., Labia, S. O., Geerinckx, C. E., Puydt, E. D., Bolders, A. C., Claes, B., & Blot, S. I. (2010). An evaluation of family-

centered care services and organization of visiting policies in Belgian intensive care units: A multicenter survey. Heart &

Lung, 39, 137-146. doi: 10.1016/j.hrtlng.2009.06.001

Whitcomb, J. A. (2010). Evidence-based practice in a military intensive care unit family visitation. Nursing Research, 59, S32- S39.

Retrieved from http://www.google.com

White, S. K. & Edwards, R. J. (2006). Visitation guidelines promote safe, satisfying environments. Nursing Management, 21-24.

Retrieved from http://www.nursingmanagement.com

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ICU VISITATION…THE EVIDENCE IS OUT THERE …2011\Tomlinson.pdf · ICU VISITATION…THE EVIDENCE IS OUT THERE Theresa Tomlinson RN, BSN York Hospital Open Heart Intensive Care Unit