Transforming Care: Developing a Patient- and Family-Centered ICU

2014 - 2 April – Patient- and Family-Centered Care
Mary Gagnon, BSN, RN; Sharon Dickinson, MSN, RN, CNS-BC, ANP, CCRN; Pauline K. Park, MD, FACS, FCCM; Lena M. Napolitano, MD, FACS, FCCP, FCCM
Learn how one surgical intensive care unit established an environment revolving around patient- and family-centered care.
Patient-centered care in the intensive care unit (ICU) requires a commitment by the ICU team to the “Right Care, Right Now,” delivering the right care at exactly the right moment to achieve optimal patient outcomes. But in addition to this important goal, our team, the surgical intensive care unit (SICU) at the University of Michigan in Ann Arbor, Michigan, USA, began a journey in 2005, seeking to establish the ideal patient- and family-centered care (PFCC) experience. To accomplish this, we assembled a multidisciplinary team to establish an environment that fosters the concept of being continually responsive to the needs, priorities and choices of patients and their families.

The SICU is a 20-bed unit caring for a wide variety of critically ill adult surgical patients (general, specialty and transplant surgery). It also serves as a regional acute respiratory distress syndrome referral center for extracorporeal membrane oxygenation (ECMO). In 2005, the unit transitioned to having all patients cared for by a multidisciplinary ICU team, led by a board-certified surgical or anesthesiology intensivist. Evidence-based critical care was promoted, using standardized protocols and policies and implemented strategies to prevent complications in an effort to achieve optimal patient outcomes.
Utilizing evidence-based practice guidelines from the Society of Critical Care Medicine, the American Association of Critical-Care Nurses and the Institute for Patient- and Family-Centered Care, our concurrent goal was to adopt the concept that patient- and family-centered care is a critical component of optimizing patient outcomes in the SICU.
Our SICU team is extremely proud to have received the Society’s Family-Centered Care Innovation Award in 2011 and 2012 for these efforts in
patient- and family-centered care, which are reviewed here.

SICU- Patient/Family-Centered Care Team

The SICU-patient/family-centered care (PFCC) team is led by a senior SICU nurse (MG, more than 20 years in SICU) and includes all individuals who participate in SICU patient care. This team was formed to set forth guidelines surrounding open communication and family participation. To initiate movement toward the ideal patient- and family-centered experience, we first performed an in-depth assessment of the current state by reaching out to our SICU patients and families. They helped determine what we needed to improve and change.

Patient/Family Inclusion in Rounds
One of the first changes that we made was to include patients and families in our ICU rounds twice daily.  We also eliminated formal visiting hours.  We believe that family, friends and patient advocates are not visitors but rather an integral part of the ICU patient’s care.  Families may be present during procedures if desired, and we make every effort to educate them regarding the patient’s illness and the ICU care required. 
Patient/Family Debrief Meetings
We established patient/family debrief meetings by inviting SICU patients/families (of both survivors and deceased patients) to gather information surrounding all aspects of their SICU experience. A trained facilitator was used, and the participants were provided with questions in advance. They were asked to begin the discussion by relating their “story” (i.e., what brought them to the SICU, what they remembered most, suggestions for improvements, and identification of strengths). The entire multidisciplinary SICU team participated. We listened and then had the opportunity to ask questions. A true sense of the fear and confusion of both patient and family in the ICU setting was clearly understood, as well as recognition of the practices and actions of the SICU team that did or did not aid in their ability to cope. This panel provided specific information that validated current SICU processes that were beneficial and provided direction for additional strengthening of the patient/family-centered care environment. These patient/family panels were most important for our chronically critically ill patients, particularly those who spent months in the SICU. We heard very important messages from them and instituted changes to address each identified issue.

ICU Diary Project

Journaling is an effective way to decrease the stress of patients and families during their ICU experience. It is helpful to have a record of the ICU events they may be unable to recall. We initiated a project to provide diaries at admission for all SICU patients with an expected length of stay greater than 24 hours. This project was made possible by the generous donation of a family member of a previous patient who found this process helpful and stress relieving. The SICU diary is used by patients and families to organize thoughts, but it also improves communication during ICU rounds by providing a place to record questions and the ICU plan for the day. We have had excellent feedback from SICU families confirming that this significantly decreases stress for both patients and families. A note that explains the journal’s purpose and how to use it (Figure 1) is included in every diary.

Other Patient-Centered Care Initiatives

We employ a number of other patient-centered care initiatives, including pet therapy (patient’s pets and therapy pets), music therapy (guitar and harp), art therapy (watercolor, doodling, weaving, beads), and massage therapy.

Early Mobility 
Our early mobility initiative is a critical component of our patient-centered care goals, particularly since it allows involvement of family members. The family’s feelings of hopelessness and helplessness can be harnessed and used to provide a sense of purpose in the patient’s recovery, to empower a connection with their loved one, and to decrease the complications of bed rest, including pressure ulcers. Family participation in early mobility also enhances relationships between the ICU staff and family and can even decrease staff workload. All of our patients are included in early mobility, including our ECMO patients who are cannulated via the right internal jugular vein with a dual-lumen bicaval ECMO cannula.
End-of-Life Care:  Keepsakes and Mementos

Our patients are regularly assessed for their understanding of their illness and the need for intervention.  Conversations about goals of care are a critical aspect of our philosophy. Discussions can include hospice care, transport home, ceasing the acceleration of care, or withdrawal of life support. We have integrated consultation with our palliative care team early in the ICU stay to establish goals of care for specific ICU patients. When it is clear that the end of life is near, we provide a number of keepsakes and mementos for the family. The SICU team donates their time, effort and funds to establish memorable keepsakes for our patients at the end of life. 
Bereavement Hearts: Dual ceramic hearts are given to the family, each containing the following message: “Please accept this ornament as a token of sympathy on the loss of your loved one. This heart and its separate pieces are symbolic of your sadness and of the bond we share with those we love, which death cannot break. You may choose to keep the heart as it is, split it between family members, or send a part of it with your loved one to symbolize your separated but unbroken bond of love. This heart was hand-made by nurses in the SICU. We offer our sincere condolences and many blessings.”
Bereavement Blanket: These blankets, knitted by our SICU staff, provide families with a personal keepsake at the end their loved one’s life. 
Patient Handprint: We create handprints of the ICU patient. These are given to the families as keepsakes.  ICU death is particularly challenging when the patient is a young child, and this provides a tangible memento.

Patient-Centered Care and Improved ICU Outcomes

We have an exceptional team. Everyone is dedicated to patient-centered care, making the patient the priority. Our SICU patients and their families become part of our SICU family – we truly care about them. We have a group of past SICU patients who serve as passionate volunteers to provide support for current patients. Many of the volunteers are survivors of acute respiratory distress syndrome.
The team that works together in patient- and family-centered care – ensuring compliance with patient care goals for both life and death – also works closely to implement evidence-based practices in the SICU to improve patient outcomes. We have achieved significant sustained reductions in ventilator-associated pneumonia and catheter-related bloodstream infections, resulting in receipt of the U.S. Department of Health and Human Services and Critical Care Societies Collaborative’s Outstanding Achievement and Leadership Award for reduction of healthcare-associated infections in 2012.
Overall SICU outcomes are monitored by all-cause mortality rates. Our ICU standardized mortality ratio decreased significantly from 0.75 to 0.38, representing a 62% reduction in ICU mortality compared to national benchmarks, despite significantly increased acuity by admission Acute Physiology and Chronic Health Evaluation III score.​