Family-Centered Care Award Summaries
Each year at the Society of Critical Care Medicine's annual Critical Care Congress, the Society's Patient and Family Support Committee awards the Family-Centered Care Award. The award recognizes innovation that improves the care provided to critically ill and injured patients and their families. Listed below are the 2011 award recipient and honorable mentions. For award recipients and honorable mentions from previous years, please visit the Family-Centered Care Award Archives.
Learn about next year's award and the application process.
2011 Family-Centered Care Award Summaries
At the 40th Annual Critical Care Congress, SCCM's Patient and Family Support Committee awarded the seventh annual Family-Centered Care Award to The University of Michigan Hospital & Health System in Ann Arbor, Michigan for their Surgical Intensive Care Unit – 5D. Honorable mention was given to The Texas Children’s Hospital in Houston, Texas for their You and Your Child’s Tracheostomy Team and University of Florida Shands Jacksonville Medical Center in Jacksonville, Florida for their Proactive Rapid Response Team.
Award Recipient
The University of Michigan Hospital & Health System Surgical Intensive Care Unit – 5D
Ann Arbor, Michigan
Front row seated left to right: Rick Rinesmith, Environmental Services; Gina McKenna, RN; Maureen Schuster, Unit Host; Mary LaBeske, RN; Cheri Macklin, RN; Dale Dietrick, RN; Kathy Kasperski, RN; Paula DeCastro, RN; Art Nowosatko, RN; MaryAnn Bettis, Nurse Manager
First row standing left to right: Mary Gagnon, RN, Chair of SICU Family Centered Care Group; Pauline Park, MD, Co-Medical Director; Chris Wisniewski, RN, Twila Wilson, RN; Stacey Lee, RN; Carla Cross, RN; Andrea Semaan, RN; Connie Rickelmann, RN; Rick Matthews, Environmental Services
Second row standing left to right: Carrie Tackett, RN; Jennifer Marschall, SICU Tech; Katy Duncan, RN; Rebecca Tulik, RN; Kelly Roe, RN; Rachel Johnson, RN; Diane Knoblauch, RN; Michelle Read, RN; Kelly Marino, RN; Loredana Bugan-Kuhn, RN
Back row standing left to right: Emily Herriman, RN; Will Sikes, RN; Orvel Bates, SICU Tech; John Tallman, RN; Rob Wonnacott, RN; Keri Bokor, RN; Nathan Wellman, SICU Tech; Todd Stubbs, SICU Tech; Steve Kelley, RN; Kevin Dube, RN; Sharon Dickinson, Clinical Nurse Specialist; Mary Ann Kurtz, SICU Clerk; Dan Lagrou, Clinical Nurse Supervisor; Lena Napolitano, MD, Medical Director
In 2005, our Surgical Intensive Care Unit (SICU) began a journey to establish the ideal patient- and family-centered care experience. To accomplish this, we assembled a multidisciplinary professional team of critical care physicians, nurses, pastoral care, social work, registered dietician, pharmacist, and families to establish an environment that fosters the concept of being continually responsive to the needs, priorities, and choices of patients and families. The SICU is a 20-bed unit caring for a wide variety of critically ill adult surgical patients (transplant, general, specialty surgery) and overflow medical ICU patients, and serves as a regional acute respiratory distress syndrome (ARDS) referral center for extracorporeal membrane oxygenation (ECMO).
In the SICU, patients are most often unable to communicate their wishes. The healthcare professionals look to the family or advocate for collaboration and information sharing. Utilizing evidenced-based practice guidelines from the Society of Critical Care Medicine (SCCM), American Association of Critical-Care Nurses (AACN) , and the Institute for Family-Centered Care (IFCC), we sought to adopt the concept that the presence of, and our care of, the family/advocate is a critical aspect in optimizing patient care outcomes in the SICU.
Family-Centered Care Committee: This committee was formed and began to set forth guidelines surrounding open communication and family participation. To initiate moving toward the ideal patient- and family-centered experience, we performed an in-depth assessment of our current state in the SICU by reaching out to our SICU patients and families.
SICU Patient and Family Panel: We invited SICU patients and families (of both survivors and non-survivors) to contribute information surrounding all aspects of their SICU experience. A trained facilitator was used. The participants were provided with questions in advance and were asked to begin the discussion by relating their "story": what brought them to the SICU, what they remembered most, suggestions for improvements, and identification of strengths that we could build on. The entire multidisciplinary team from the SICU was present to participate. We listened and then had the opportunity to ask questions. A true sense of the fear and confusion in both the patient and family in the ICU setting was clearly understood, as well as recognition of practices and actions of the SICU team that aided in their ability to cope. This panel provided specific information that validated current SICU processes that were beneficial and of help to the patient and families, and provided direction for additional strengthening of the family-centered care environment.
Patient/family participation: Embracing the concept "It’s All About the Family: A Continual Pursuit of Being Responsive to the Priorities and Choices of Families," we have established the following: creating a process for family participation in direct patient care; welcoming the families as a member of the SICU team; honoring patient/family preferences and their participation in ICU rounds twice daily, in development of the daily plan of care, and in activities of daily living.
SICU Unit Host - Preparing families for what to expect: The Unit Host (Facilitator) makes contact with the family before SICU admission (including going to the operating room waiting area), thus giving the family a familiar face and personal contact. The host then greets the family on admission, assesses their needs, gets them acquainted with the SICU, and provides useful information, such as local housing and SICU contact numbers. The host makes contact with pastoral service, social work, music therapy, and pet program as appropriate for each patient/family, and provides disease-specific information packets to families, such as "Understanding ARDS: Its effect on victims and loved ones."
Elimination of formal visiting hours: We believe family, significant others, and patient care advocates are not visitors, but an integral part of the ICU patient’s care. To that end, there are no posted visitation hours. Someone is welcome to stay at the bedside 24 hours a day if desired. Children are welcomed to the unit when the adult patient or family member deems it is in the best interest of the patient and child. Families are welcome in the SICU at all times.
Support and encouragement of family presence on rounds: Families are informed as to the time and process of SICU rounds and are invited to be present when these occur twice daily. The multidisciplinary team gathers at the patient’s room and reviews pertinent data regarding the patient’s status with the family in attendance. Families are encouraged to interject or clarify information. Family support can help a patient feel less alone and vulnerable among strangers. Communication and information sharing are open and objective. The team sets forth the plan for the day, and it is communicated to all members of the healthcare team and family. If a family member is not able to participate on rounds, the patient’s current condition and plan are discussed via phone conversation. A daily goal sheet is utilized to keep all members of the team (including families) informed as to the plan of care for the day. We have added “family updated” as a daily goal on our checklist, which is read aloud every morning during ICU rounds.
Fostering and supporting family presence not only during routine care but also during periods of crisis: This includes, but is not limited to: resuscitation, intubation, line insertions, and cannulae placement for ECMO. This paradigm shift for family presence at procedures remains highly controversial among healthcare providers and thus is far from the norm in many ICU settings. We believe it is the basic human right of patients and patients’ families for the families to be present if they desire. We utilize a Unit Host, management, pastoral care, or the bedside registered nurse as the family facilitator in preparing individuals, as well as supporting them before, during, and after the procedure.
Promoting the "stay connected" concept: In an effort to raise the standards around family-centered care, an innovative approach, the "stay connected" concept, was initiated. This allows patients and families to connect with the outside world through a number of initiatives. Volunteers read the daily newspaper (or other material chosen by the family) to patients when family cannot be present. For our longer-stay ICU patients, we make every effort to take the patient outside (even those on mechanical ventilation). We find it beneficial for both patient and family to feel the sun, hear the birds sing, and remember life outside of the SICU. We further ask for and encourage the use of iPods and other media for music therapy. We help family to place pictures of loved ones around the room and on ceilings over the bed. We decorate patient rooms for the seasons and holidays. Instead of exchanging gifts within our SICU team at Christmas, we pool the contributed funds to purchase gifts for our in-residence SICU patients to give to their family/loved ones.
Pet visitation in the ICU: Pets are allowed to visit patients in the SICU after the animal’s health is confirmed via a written veterinary health certificate and in compliance with our Pet Visitation Policy, which includes proper infection control for animals during the visit. Patients and families that participate in this program find it very rewarding. This fulfills Recommendation 6 from the SCCM guidelines: "Guidelines are created for animal-assisted therapy."
Music and art therapy: Music therapy is provided by volunteer musicians in the SICU, with guitar and harp musicians providing music for individual patients, particularly our long-term ICU patients. Music therapy helps our SICU patients reduce anxiety, increases relaxation and ability to cope, and also is soothing to visiting families. Our facility Artist in Residence visits the unit weekly to provide simple arts and crafts for patients and/or family.
Palliative and end-of-life care: As recommended by the SCCM guidelines, end-of-life care is a priority, and we fully disclose the patient’s current status and prognosis and explain all reasonable management options in the context of family meetings with the multiprofessional SICU team. Families are offered referral to palliative care, and we have developed electronic palliative care orders to facilitate all appropriate palliative care once that decision has been made.
SICU renovation: We renovated six single-bed rooms and seven double-bed rooms with curtains for separation to 20 single-bed rooms with glass doors that can be made opaque for improved patient confidentiality, privacy, and family support. This significantly reduced noise levels in the ICU rooms, improving the biopsychosocial health of the patient and family. Significant hospital commitment with capital investment was provided to accomplish this renovation.
SICU waiting room renovation: We added computers to the two SICU waiting rooms, providing a link to the SCCM Patient and Family website and the ability to create "Care Pages" to keep family informed (http://www.med.umich.edu/carepages/).
Efficacy evaluation: To evaluate the effectiveness of our goals and interventions, we explored family satisfaction with care rendered in the SICU. A family/patient satisfaction survey was distributed between April 1, 2010 and June 10, 2010, to evaluate outcomes related to our goals. Results: Thirty-six patients/families have responded to the survey. The results show positive outcomes in the following categories, as ranked by good to very good: Overall communication: nursing 97%, physicians 80%, social work 50% (39% no opinion), respiratory care 63% (17% no opinion); Pain: 100%, diagnosis and treatment 94%, sensitivity and responsiveness 97%; Family support: 97%, family participation in decisions 82%, open visitation 94%, degree to which ICU team considers needs 97%, feelings of safety and security 97%.
Outcome evaluation: Prospective data collection (Acute Physiology and Chronic Health Evaluation III) confirmed a significant ICU mortality reduction (26% reduction) with observed/expected ratios of 0.77 (2004, prior to this effort), 0.59, 0.61, and 0.51 over the last four years.
Implications/conclusions: The multidisciplinary critical care team can meet ICU patient and family needs and improve the quality of ICU patient care by implementing effective strategies to increase patient/family access and participation. Improved communication with the multidisciplinary ICU team created a patient- and family-friendly environment. Family support in the patient-centered ICU is associated with significantly improved ICU patient outcomes.
The University of Michigan Hospital & Health System is congratulated and commended for its strong commitment to improving both communication in the ICU as well as the critical care experience.
Honorable Mention
The Texas Children’s Hospital You and Your Child’s Tracheostomy Team
Houston, Texas
Back row from left to right: Juli Teeters, CCLS, Child Life Specialist; Emily Charles, RN, Care Manager; Jeanine Graf, MD, Tracheostomy Team Coordinator; Mona McPherson, MD, MPH; Vivian Clark, LMSW, Progressive Care Unit Social Worker; Shora Gasca, RN, Progressive Care Unit Care Manager; Cindy Thompson, RN, Progressive Care Unit Care Manager
Front row from left to right: Katie Evans, LMSW, Pediatric ICU Social Worker; Barbara Montagnino, MS, RN, CNS, Progressive Care Unit Clinical Nurse Specialist; Jeanetta Holley, Administrative Support Coordinator III
Development of a Pediatric Tracheostomy Team
Our tertiary Pediatric Intensive Care Unit (PICU) and Progressive Care Unit participate in the care and treatment of a large number of technology-dependent children. Among the most complex patients are children who require an artificial airway as part of their medical management. A review of our practice demonstrated that pediatric patients with a new tracheotomy require an average of three additional weeks in the hospital to complete training involving their technologies, but the amount of training time varied widely. In addition, we found that families of children with new tracheostomies experienced multiple barriers (social and medical) to education and discharge. In an effort to empower and educate families, our collaborative team developed a comprehensive and anticipatory approach to assist them as they face tracheotomy surgery.
A multidisciplinary team of pediatric intensivists, care managers, social workers, a clinical nurse specialist, and nurses formed a collaborative alliance known as the Tracheostomy Team. This team supports families to address their educational, resource, and emotional needs. Our hospital's auxiliary has partnered with the Tracheostomy Team and generously funded the production of the Tracheostomy Caregiver's Handbook. The following components and process have been developed:
- Tracheostomy Consult Team: Team members use their expertise with critically and/or chronically ill children to assist both families and the medical team caring for patients facing a tracheotomy procedure. The team meets with families preoperatively to ensure they fully comprehend the implications of caring for a child with a tracheostomy and to assist with applications for financial assistance. The team assists the medical team by addressing common social limitations to education and discharge (e.g., language barriers, transportation, sibling child care, home resources, and parental anxiety).
- Tracheostomy Caregiver's Handbook: A comprehensive guide was developed in both English and Spanish to provide families with educational materials, financial resources, emergency resources, calendars, and checklists. This handbook allows families to organize their children's medical care and their multiple checklists.
- Skills and Discharge Checklist: A comprehensive bilingual checklist was developed, providing details on tasks and items needed for discharge. The checklist serves as a shared worksheet for all caregivers, both family and the medical team. It serves as a visual aid to track progress toward transitioning the child out of the hospital. Under the watchful eye of nurse trainers, the family demonstrates proficiency in all aspects of care.
- Medical Team Roadmap: A clinical pathway with daily goals was developed for the medical team to direct the planning and delivery of consistent care. This roadmap also facilitates the education of multiple team members and trainees who participate in the care of these complex technology-dependent children.
Process
PREOPERATIVELY: The clinical nurse specialist, social worker, and care manager arrange to meet with the family to review their understanding of the therapeutic goals of the tracheostomy. The team explains the expected medical course postoperatively and the anticipated training period. The family and team review mutual expectations of care and training for the child. The social worker offers emotional support, reassurance, and guidance. The team reviews the child's eligibility for fiscal resources and assists with applications. The care manager discusses and reviews anticipated home care needs.
POSTOPERATIVELY: The Tracheostomy Team encourages the family to utilize the immediate postoperative time as a period of rest. After a week in the PICU, the child is transitioned to the Progressive Care Unit under the care of pediatric intensivists, where the family receives carefully structured training. The family is given a copy of the Tracheostomy Caregiver’s Handbook. The team reviews the Discharge Checklist and Roadmap with members of the clinical team and family. Tracheostomy Team members participate in daily collaborative, family-centered bedside rounds with the medical team. The team is available for additional contacts as needed, ensuring that families are supported and encouraged throughout the training program. Child care for siblings is provided during the family's training period if needed. Once the family chooses their child's medical home, the team contacts outpatient providers to assure a seamless transition of care.
DISCHARGE: The team ensures all training is successfully completed, and the family and child are eligible for discharge. All follow-up appointments are arranged and placed in the handbook calendar. The care manager calls the home nursing company and/or family 24 hours after discharge to assure a smooth transition and to answer any questions.
This program has been in place for 18 months. To date, more than 50 families have participated. We have distributed 100 Tracheostomy Caregiver’s Handbooks to both families and colleagues in outreach. We have received overwhelmingly positive feedback on the success of this program.
We continue to seek collaboration to build on the momentum of our first 18 months. Additional outreach by the Tracheostomy Team has included educational initiatives to our otolaryngology and pulmonary colleagues, and to subacute pediatric hospital providers in our region. Our partners in neonatology have adopted the handbook as a model for their training program. Future educational efforts in the next 12 months include a one-day seminar for medical providers of children with tracheostomies in the outpatient setting (e.g., home nurses, school nurses, home health agencies, general pediatricians).
In summary, the Tracheostomy Team offers families an innovative structured and comprehensive approach when facing the prospect of caring for a child with a new tracheostomy. Our collaborative program empowers and supports families as they learn to care for the technology-dependent child. The goal of the Tracheostomy Team is to facilitate the child’s transition from the PICU to home while meeting the needs of the family.
The Texas Children's Hospital is congratulated and commended for their initiative and success in improving their ICU.
Honorable Mention
University of Florida Shands Jacksonville Medical Center Proactive Rapid Response Team
Jacksonville, Florida
From left to right: Karen Wilkerson, RN, RRT, Staff; Veneree Hall, RN, RRT, Staff; Cynthia Gerdik, Director of Critical Care Nursing; Zane Kimble, RN, RRT, Staff; Bernice Israel, RN, RRT, Staff; Annette Wall, RN, RRT, Staff; Kristy Kingston, RN, RRT, Staff
In conjunction with the University Health System Consortium (UHC) Patient- and Family-Centered Care Implementation Collaborative, our hospital launched a phased critical care outreach rapid response program in July 2007 that included allowing patient and family activation of the rapid response team (RRT). Our RRT is unique in that the nurse team member is an intensive care unit (ICU) nurse without an assignment. The hospital adopted the original research for RRTs and implemented a critical care outreach or proactive rounds on patients transferred out of ICUs to help prevent “bounce back” and code blue calls, and to enhance family and patient comfort and satisfaction. Many patients transferring out of ICUs and their families are fearful of leaving the perceived safe environment. On each shift, twice daily or more often if needed, the rapid response nurse checks on patients who have been transferred out of an ICU for a minimum of two days. The transferred patient and the family are instructed by the ICU rapid response nurse that calling the RRT is like calling 911 from home. This proactive rounding approach for transferred ICU patients in medical-surgical and progressive care units quickly expanded to include patients with potential airway challenges such as tracheostomies, halos, postoperative epidural patient-controlled analgesia pumps, chest tubes, or heparin drips and any other patients identified by the nursing staff or physician as needing this extra ICU nurse assessment. On each shift, the RRT nurse proactively rounds on 35-45 patients. In most months, the RRT nurse receives approximately 200 calls in the larger campus hospital and 60-80 calls in the smaller campus hospital. Staff are encouraged to call fast and often, and most calls are received via direct cell phone to the RRT nurse because an overhead page can be intimidating to the inexperienced nurse. The proactive rounds have evolved into a patient safety initiative; the RRT nurse ensures a backup tracheal tube is present at the bedside for those with a tracheostomy. The RRT nurse wears bright orange scrubs so as to be easily seen in a crowded corridor or at the bedside of a patient in distress. Many staff, physicians, patients, and families fondly call these individuals the “orange nurses.”
After initial phased implementation of the RRT, there was a significant decrease in non-ICU codes (P<0.01, analysis of variance), from 25.2 (10.9) monthly to 17.4 (6.6) monthly [mean (standard deviation)]. The number of patients who expired at the time of the code (failure to rescue) went from 12.3 (5.1) to 5.9 (4.3) to 3.2 (2.2) monthly. A review of the first two years’ data indicates that the RRT received 25 patient- or family-activated calls: 48% of the calls were initiated by a family member and 52% by the patient. Reasons for those calls have varied, but the most frequent one identified was “something just doesn’t feel right” with the patient. Calls from patients or families have been similar to those initiated by staff, such as shortness of breath and pain issues.
Of the 25 calls received, only two were determined to be non-urgent. A patient called complaining that his intermittent needle therapy site was pulling the hair on his arm; the RRT nurse changed his dressing and gently reminded him that he may not have called 911 from his home for something like this. Another patient called the RRT nurse because his green beans were cold; the RRT nurse assessed that he had challenges with chewing, so a nutrition consultation was performed and the patient’s diet was changed to pureed foods. There was the transferred ICU patient whose neighbor was visiting him and suddenly developed slurred speech. The patient remembered the RRT nurse’s instructions, so he reported that he thought his neighbor was having a stroke; the RRT nurse responded and took the visitor to the emergency department as a stroke alert patient. A newly transferred ICU patient with a tracheostomy had been instructed that he or his family could call the RRT anytime; less than 20 minutes later, the wife called the RRT nurse, because her husband wanted to see how fast the response was. The RRT nurse returned to his room in four to five minutes. It was only then that the husband told the wife she could go home and gets some rest, as the “orange nurse” could look after him.
This is one of few critical care outreach (proactive rounding) rapid response systems, and one of the first adult hospitals to initiate a patient- and family-activated component of RRT systems that has led to improvements in outcomes, such as the reduction in non-ICU codes and failure-to-rescue rates without an overload of false-positive calls made by the patients or families.
The University of Florida Shands Jacksonville Medical Center is congratulated and commended for their initiative and success in improving their ICU.
