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How do families impact patient outcomes in the ICU? What does it really mean to engage and empower families in the ICU? Have our teams truly recovered from the strict visitation restrictions from COVID? How does an ABCDEF Bundle culture influence our visitation policies? Lito Rama, RN, MBA joins us now to share with us the vast evidence supporting families in the ICU.

Episode Transcription

Kali Dayton 0:00
Sure, sure. Thank you, Lito. Welcome to the podcast. Tell us all about yourself.

Lito Rama, RN, MBA 0:08
Thank you. Thanks for having me. So, um, I’m Lita. I’m a critical or critical care registered nurse. So basically I started my career in the Philippines as an ICU nurse. And then I got promoted as a unit supervisor in the ICU. But then I decided to move to the UK. So I work in London guyson St. Thomas’s, it’s known to be one of the biggest hospital in the UK.

And then it was also the hospital. St. Thomas’s that was founded by Florence Nightingale. Um, I mean, five years ago, I moved here in the US in Houston. I started working here as a heart failure ICU nurse before I move up to leadership. I’m recently I think, last month, I just finished my MBA Mays Business School at Texas A&M.

Kali Dayton 0:54
Congratulations.

Lito Rama, RN, MBA 0:55
Thank you. Um, that’s actually my second master’s since I finished my master’s in nursing at the University of the Philippines, where I’m also currently being offered her master’s program. I’m currently I’m I’m, I’m enrolled at Harvard medical school’s, leadership in medicine, Southeast Asia, so we’re aiming to finish, hopefully, Feb. 2024. And, yeah, thank you. Yeah,

Kali Dayton 1:21
absolutely. I saw your recent publication, talking about liberal visitation in the ICU. And I got really excited. I loved even that term “liberal visitation”. So with your all your combined experience in all these different countries, what inspired you to publish this article, focus on visitation in the ICU?

Lito Rama, RN, MBA 1:43
Yeah, just to give you a background, so when I conceptualize this research is topic like, I was still living abroad. So basically, I was like working as a unit supervisor in one of the ICUs, I’ll say to us, and then we’re one of the two ICUs, or hospitals in that country that practice liberal visitation. And then there was like a push at that time from a lot of stakeholders, for us to reverse back the policy to restrict the visitation. So that’s

Kali Dayton 2:14
Really? What were their arguments?

Lito Rama, RN, MBA 2:18
thing is pretty common, like, additional burden, additional workload to their nurses, and maybe like, you know, some of the family members can be disruptive to patient care. But um, there’s also another situation that happened, like one of my friend, his dad get admitted to an ICU, and we work in same hospital.

And then during our conversation, like he mentioned, like he hoped that the ICU is where, where his dad was admitted, that we’ll have like, almost same policy. In our ICU we’re in like, we allowed 24/7 visitors because like, there’s a lot of stress like, and also anxiety, not only with the family members, but also the patient, because they basically can’t see their relatives.

It was like very restricted, they only visit like two hours. And there’s only a limited time, like, certain time, some of them are working. So you know, various restrictions to the vistitation policy. So that’s why I was like, it’s a good topic, I think it’s, it’s very beneficial to the patient. However, like I think, often like as an ICU nurse, we usually focus on hemodynamics. And you forget that there’s like psychosocial needs of the patients.

So that’s why I tried to explore on the topic, and then I found out that majority of the published research on on liberal visitation are focused on family, like the effects in the family. So there’s, we have a few publications on that one already. And then the other ones focus on the perception of the healthcare workers. So we have lots of letters on that one.

But there’s very few articles or research that explores the benefits of liberal this liberal distinction when it comes to the patient. So maybe, because like, a lot of our IC population, they’re like vulnerable patients. So it’s really hard like to conduct research on that special population. And I think I encountered the same like, you know, like barriers when I was like looking for a setting for this.

Um, so but then luckily, I was able to conduct a study on for a five month period, we successfully recruited like 50 patients. And we explored like, three factors, basically, we look into the anxiety of the patient, because there was like a previous article in 2006, that explored like liberal visitation. And then they found that there’s a decrease in cardiac complications. And they, they, they thought that it’s probably because of the decreased level of anxiety. So that’s why I choose that that factor or that variable, and then also satisfaction of patients.

And then length of stay. And then we found that there’s a decreased level in patients anxiety for those who are enrolled in Liberal dissertation, and then also increased satisfaction for the patient. However, for the length of stay, there’s not a significant difference, probably because when we when it comes to like length of stay, it’s multifactorial, there’s really a lot of factors that affect our length of stay.

So maybe like the bed availability, for example, like to downgrade those patients. And then at the same time, like, in South, there’s like two research that I found, like a one was comparing the length of stay in the ICUs. In the US, as well as in Europe study found that our length of stay here in the US is a bit longer.

When it comes to the ICU, you know, ICU length of stay takes a bit longer when compared to Europe. And then the other study, they look into the length of stay of ICUs in the US, as well as Japan, they also have the same findings or a length of stay a bit longer. So those are just a few factors. But I think that I think there’s more. So basically,

Kali Dayton 6:20
How did you measure their anxiety? Was there a scale or tool that you used?

Lito Rama, RN, MBA 6:27
Yeah, So we, we use validated scale, we have the phases anxiety scale. So it was like, there was that was also like, used to like an IC population. Before I think there was an Australian study for that one. So I connected with one of the auditors, and then they gave me the the validated instrument, and then I use that one for my study.

Um, yeah, one of the challenge also, in measuring the anxiety for ICU patients is like, most of the tools are like, it’s very likely. And if you’re in the ICU, like, I can’t imagine them, like filling out those forms, which I like, you know, very likely. So I was looking for like, a tool, which has, like, I’m quite short, like that can like they can finish within like one minute that won’t add burden for them. Because like, if I have a tool that’s quite long, I will probably have more challenges with recruitment. So that’s why Yeah, I used to face inside the scale.

Kali Dayton 7:32
And the cognitive demand right? To fill out an extensive tool takes a lot of cognitive capacity. Were you able to…. I mean, what role did delirium play in all of this?

Lito Rama, RN, MBA 7:46
So the delirium, like, for this one, so I think that’s one of our exclusion. So we, we are very selective when it comes to our inclusion criteria. We want to make sure that, you know, during that delirious edit, we’ll have more accurate, like, um, anxiety levels, and we’re collecting the data.

Kali Dayton 8:10
And we have previous or other studies that show the impact of family visitation, again, to protect or to treat delirium. So I guess that element of family and impact on delirium has already been measured, right. But yes, delirium can be a root cause of anxiety period.

Lito Rama, RN, MBA 8:28
Yeah, I believe so. Yeah. Okay.

Kali Dayton 8:31
And so, through your study, we’re seeing that it decreases patient anxiety, improves patient satisfaction, and had no effect on the length of stay. But like you’re saying, it’s multifactorial, that could be disputed in different angles. And so combining what your findings with the other studies that we have to show that it decreases delirium improves the family’s experience, the family trauma.

Why are we still having these conversations? Like why is this still a thing? Why isn’t liberal visitation standardized? And I kind of want to look at the whole history, right? Because we know that there have been trends going on throughout hospitals in general, especially in the ICU. So historically, how did family visitation even start?

Lito Rama, RN, MBA 9:21
So I think history? Historically, like we all we always have, like a restrictive visitation policy in our ICUs I think it goes back to like, I think there’s like a fear or more, it’s more like infection control. So there’s, there’s like this perception that finally visitation will increase the risk for infection or vulnerable ICU patients.

Kali Dayton 9:45
That’s been debunked, right? We’ve proven that that’s not true.

Lito Rama, RN, MBA 9:49
Yes, yeah. I think um, there was like a study that pointed this one out, but into those and said, Yeah, six Yeah. Fumagalli like he did like a randomize control trial in the ICU, and I think this was conducted in Italy, and then they found out that there’s no direct infection risk for the patient.

Environmentally, though, in that study, they found that yeah, there might be like increased like bacteria in the ICU, but it doesn’t really contribute to like the infection or Legionella sepsis or anything that contributes to like infection in in our ICU patients.

So there was already like, this group. Um, but then the studies 2007, like, at that time, like majority of our ICU is still restricted. And then there was also also study, senior year it was gonna in Belgium, like 100% of the ICUs are restricted. Surprisingly,

Kali Dayton 10:44
Like forever ago, right. 2007? You know, it’s a long time ago, and yeah, it just it doesn’t it doesn’t feel like we’ve made that much progress. But we did for a bit. Right?

Lito Rama, RN, MBA 10:57
Yeah, And then yeah, so because of the I think, because of the studies that was conducted, like, I think there was like the recommendations. I think it started with the American College of girl Care Medicine, back in 2007, so the recommended liberal list station, and then ACN, the American College of Nursing, not sorry, Americanization, grilled care nurses, sorry about that. On 2011, they also endorsed liberal visitation and British Association of critical care nurses on 2012 push for a liberal visitation.

But after this recommendation, like they’re presenting like evidence, they’re still when we look at this one, there was a study in 2013. So this was after like, three years, you know, huge bodies of healthcare organization endorsed liberal visitation, 2013 94% of hospitals. So I think there was a study that they surveyed 606 hospitals, so like, 94% of them still practice, like restrictive visitation.

And then even in 2019, this was like pre COVID. Like, there was a survey conducted, like, with magnet hospitals, like 404 Magnet hospitals, and then 130 Pettaway hospitals. So only less than 20% of them practice like liberal visitation.

Kali Dayton 12:25
Really? I guess, in my mind, because I practice in an awakened walking ICU from 2013 on and they had been open to the public, I mean, just open the visitation for many years before I ever started working there. I totally thought that that was normal. In addition to having patients awake and walking, I was very disillusioned, right. I thought that that was standards when I went to elsewhere.

And suddenly the doors were locked, and then wasn’t really there. And it was super restricted. It was so confusing. So I guess I guess in my mind, I assumed that she doesn’t, she doesn’t inteins was like, Renaissance period, when we looked back and saw, Wow, we’re really doing a disservice to our patients. This isn’t humane, let’s open the doors. But she doesn’t have 19 less than 20% had liberal visitation. So apparently, I was part of that. Less than two 20%. But that’s really disheartening, I thought that we’d made more progress. And that was just COVID. That took us back.

Lito Rama, RN, MBA 13:24
Yeah, that’s what it was, was it was also my perception, because like, as Linda mentioned, I started with a hospital that has liberal visitation. And then when I moved to the UK, we were also like, we also like a very liberal visitation policy, like we’re open to visitors. 24/7. So I thought that’s the usual practice and looking at the articles.

I think that’s what’s the practice for majority of the hospitals. We especially like teaching hospitals. But I think one of the findings in one of the studies is like, the liberal visitations have been more practice in hospitals, smaller hospitals, less than 150 Bed hospitals, they’re there, they’re having like, it’s more common in their ICUs, probably because of their acuity probably might not be too high. That can be one of the factor.

Kali Dayton 14:08
It’s smaller hospitals control the variables more. They’re in rural settings, small town. I mean, it’s hard to tell your neighbor that they can’t come in to see their wife. Yeah, even telling a stranger that lives in another state. You know, I think that probably is a big variable as far as the culture in those areas.

Lito Rama, RN, MBA 14:27
Yeah, I agree. I agree on that one.

Kali Dayton 14:29
Yes. And so where are we at now or just kind of even internationally? So you’re talking about the UK was open visitation, but the US was much more confined? What do we know about throughout the rest of the world?

Lito Rama, RN, MBA 14:46
Outside the US like so based on my experience, we’re open. I worked in London at that time. So and it’s also like a big teaching hospital. So we’re most of our ICUs are really open but when you look at the data in the UK Like, but this was like, done like 2010 today that one of the reasons I’ve seen like 80% of their ICUs are restricted.

So Belgium I mentioned earlier, they have restricted visitation before all of these recommendations were published. But even after the recommendations were published, there was like a study that was conducted, still 100% of their ICUs are restricted. And then Brazil, they only have like 2.6% of their ICU, who was practicing liberal visits. And then there was a study by De Silva was like, really, like, he pointed out some factors like in there in Brazil, for example, one of the factors like this, like resistance from some stakeholder, if they come from the nurses, doctors, they’re not really convinced on the benefits of liberal visitation.

And another factor is like, the facilities like, there’s not enough space for the visitors in the ICU. And some, some of the hospitals don’t even have like a waiting area where the visitors can stay. So those factors, and I think, in the, in the, in the Philippines, or originally like, you know, started my career, like, in all of the hospitals, like we only know, like, two hospitals that has liberalisation.

And one, one of them was at that time was trying to reverse that to like, restrict the visitation. And then, and I think they’re, I remember, like, there was also like a study like, it was cited that like, although there’s like, some improvement in Europe, when it comes to open visitation, a lot of hospitals are looking into like reverting back to restricted visitation. If even me during p COVID. You know, before 2019, yes.

Kali Dayton 16:56
Which is wild. And that’s that was that’s customers happening, and then COVID hit? Yeah. And all the doors were shut. Yes.

Lito Rama, RN, MBA 17:04
All those were tied. So yeah, so funny, like, I graduated, like, October 2019. So I presented this research in one of the conference, like, Filipinos zoom conference in Manila. And that was like October, and then I even flew to China, like on the same month, like the trowel, and then I think November, that’s when the COVID happened in China and just like a few months, so it was also exploring, like, I was trying to publish this study, but then all the ICUs were shutting down.

And I think it was no longer current. So that’s why it took time before I got this month published. Because like, at that time, I think all the ICUs even like, med surg unit, or, you know, closing their doors for visitors because of the infection. And I think even now, like, I know, we still have data, but I think we just started to reopen based on my experience, like, it’s less than a year before we started reopening our doors, select visitors, or like, you know, like liberalizing visits, even in mesures areas, I think it will take time, you know, before we will go back to our baseline in the Pre-COVID period.

Kali Dayton 18:26
Absolutely. Or… and I would hope now that I realized that even pre COVID, we were not as progressive or modernized, as I thought that we were, hopefully we can learn from COVID. And really value families as an intricate part of the ICU team and a key role in the patient survival. Even though okay, maybe we don’t have necessarily exact study so that patients survive at greater rates when the family’s present.

But if we break it down, I mean, this is a podcast dedicated to delirium and early mobility. We appreciate that delirium doubles the risk of dying in the hospital. And then one study from 2021 showed that family presence for more than two hours a day decreased delirium rates by 88%.

Lito Rama, RN, MBA 19:14
Oh, yeah.

Kali Dayton 19:15
So I think inadvertently, we can be pretty confident that if we can utilize family to help patients avoid delirium, that it’s going to impact their survival.

Lito Rama, RN, MBA 19:25
Yeah, I believe so. I agree on that one. Yes. Because like, I’m sorry. Yeah. Because based on my experience, also, like during COVID era, period, like when I was working in the ICU, like, family really helps like those. Although we don’t allow them like the Zoom calls.

Like I think it really helps them like So one time I have an experience like one of the patient like family, like they have certain roles, like they give you information about the patient. So one of the family members told me okay, I kind of go in but I want to let you know that this is this patient’s favorite songs.

So I played that one on my Spotify, because like we’ve been like, like that patient for like a month already. Like he’s not waking up. So I played his favorite songs, and he woke up so like, you know, those bits, like really help? Like if we didn’t if we didn’t have the information, I don’t know if…. you know?

Kali Dayton 20:20
Absolutely! We really undervalue the expertise that families have on the patients. Yes, I think we, culturally, it’s become acceptable to demean families for not being medical, and under, just assume that they’re not relevant to this medical process. But they bring in an expertise, they are the expert on our loved one, they know what their triggers are.

Right? If you have someone that you don’t know what their past traumas, if you can’t, if they’re patient sedated, you don’t know what works, what doesn’t work for that patient. But you better believe that their wife, their mother, their husband, their child, they know them.

So to say this their favorite music, like you’re explaining it worked, it brought them out of probably this hypoactive delirium. So they know how to actually treat their loved one, maybe not with all the medical intricacies that we know. But they are the experts. So it blows my mind. Because my experience and then waking walk in ICU, which I think an awake and walking in ICU, part of the definition is that there is liberal visitation.

The families are part of the team and we don’t kick out our tea after seven o’clock at night. But there were a lot of rooms in the ICU that had built in couches, kind of like a delivery room where it was made so that families could sleep there if they needed to or wanted to. And we had no hesitation in calling them at night and saying, “Hey, your loved ones agitated, they’re anxious, can you come in?”

We use that as a tool. So for me, it’s hard for me to imagine what it’s like to practice as a nurse and not have that tool. Yeah. Or I just know that it’s really laborious to sit there and try to have them write on the board when they have poor handwriting, or they’re, they don’t speak English are just things that I hand that off to the family is to say, they’re trying to say something, can you help them and so eager to be involved and connect, and that saves me time as a nurse, it helps me as a nurse practitioner, know what medications they’re on what they need, what’s going on?

You know, it’s just part of our assessment. So I think we’re doing ourselves as clinicians a disservice to kick families out. Not all families are made the same. Yeah, we all know. And I’ve had personal experiences with families that are obstructive, and disruptive. But that’s probably depending on the area. But that’s usually the the exception. But then we punish everyone else for it. So when we’re having this discussion, because I know of podcast listeners that are going to bat for for their patients, right?

They’re trying to say, “This isn’t humane to kick the family members out, or I know my the patient has delirium. They need their family members tonight”, but they’re up against this hospital policy. So how can we dis dispute that?

I guess, so let’s do a little role playing. You be the clinician or the maybe medical director or whoever that’s trying to say we need to have liberal visitation in the ICU, and then I’ll be maybe some of the other clinicians that want it more restricted. And so sell me on it, right? We’re both like, we’re doing a debate in front of the hospital administrators. So what do we know? Why do you want family visitation to be open?

Lito Rama, RN, MBA 23:40
I think we, I think for me, we always go back to the evidence like there’s already there’s already like recommendations from like two big critical care organizations that you know, liberal visitation is beneficial to the family. And I think one of the biggest fear like one of the biggest barrier against liberal visitation is you know, the risk for infection but that was already like disproven by a by a trial that was conducted in the ICU in Italy so there was like already a strong evidence that dispute that one. So I think we should address psychosocial needs of the patient not only their you know, hemodynamic stability, because like we should approach our patient in a holistic way.

Kali Dayton 24:30
But they’re on ventilators, they don’t really talk to anyone anyways, they’re just sedated.

Lito Rama, RN, MBA 24:36
I’m still like, I think there was there’s a lot of studies that can let was conducted like, for post ICU patients, the they those ventilators actually contributed to their anxiety. They feel that they’re in maybe like, out of display, maybe In space, like because of these ventilators, these are not familiar objects and having this patient present when they open their eyes will help them that, hey, they’re here, these are the familiar people that they have. And that will make them more safe.

Because like imagine if you wake up and you have this tube in your mouth, you cannot even speak and then you don’t know anyone you’re not even familiar with environment, like you feel that you’re in an aquarium, something, that’s what they usually mentioned, to us.

Like, it really increases your anxiety. So I think having someone familiar, and that can help like interpret all those like unspoken, you know, words or reactions that you have, that will be very, very helpful. And it also helps with early recognition, recognition of pain, like your family members, if they’re present at the bedside, they can alert the clinicians and address pain on spot, but

Kali Dayton 26:01
They’re just they’re always pestering me. They’re coming out and say my lab was in pain. We’re short staffed, we don’t really have time to talk to them.

Lito Rama, RN, MBA 26:09
I think so there was like a study. This was done by MAC Adam, it’s been a while like two dozen eight. So families are really they’re vile. They’re the studies or the article mentioned that families are being unrecognized or undervalued. But then their active presence help.

We see some of them being disruptive, but a lot of them really help at bedside. So some of them are your voluntary caregivers, they some of them, turn patient like without even like or help Lina reposition them without calling the nurse. And they can be a good historian also.

And their role is basically the patient protector, make sure that the patient is safe. And they can also act as interpreters. There’s like two articles, but one was for Miguel, and the other ones that you’re asking and 2006 and 2012 that, you know, they can act as interpreters. And I think based on my experience, also, we can sometimes I ask family what this “What is she trying to say?”

And you know, they recognize it easily because they know the patient for years compared to us, like ICU nurses have been there like only for a few days or a few hours. So you know, you having this resource readily available? I think it’s the benefits is more compared to like, I mean the risk or maybe like the the additional board that perceive of having visitors in the in the ICU and I think I’m one study in particular mentioned that the absence of the family also increased psychological symptoms in the eyes, including anxiety. So, you know, there’s a lot of benefits.

Kali Dayton 28:03
But sometimes I just think that like the family just gets worked up, they get anxious, they get in the way, you know, if we’re doing CPR, they get all they could get all riled up, they kind of it just they disrupt our workflow.

Lito Rama, RN, MBA 28:18
I think we can we can put like, I think communication to them and educating them will help. I think there was also a study that mentioned like that family presence in the ICU is actually not this disruptive to patient care. And although the majority of the study like mentioned that the perception of the nurses or other healthcare professionals for the family members was being disruptive.

There was one study in 2014 in Australia and UK that they actually see that no, the family is not actually like a barrier for patient care. So I think communication and educating this family will help address that one. I remember when I was like a unit supervisor and one of the ICU so one of my nurses while examining a patient and then of course the family was was agitated because of course his patient was coughing something like that.

But I think if you talk to the relative that “Hey, I’m doing this and this might happen” like tell them in advance what’s the expectation that can probably address his issues and also that will lessen the anxiety and making them aware what will happen if you’re doing some procedures or something in the unit. And additionally like family presence during rounds that can save like time.

Back in the UK we have like a multidisciplinary rounds and we we can basically estimate what time the doctors or healthcare professional I was really present at the bedside. And having family during that rounds, if the patient will allow them will save us a lot of time from explaining all of all of the questions or addressing the questions that they have.

Kali Dayton 30:16
Okay, I can’t roleplay anymore because I ran out of cons. I don’t even I’m not very good at playing that role, because I’m totally with you. And the evidence you gave such a compelling stance on it. And yeah, you all of these citations will be available in the transcription of this episode, please go back and read the studies that Leto has referred to because the evidence is there.

I just had to think of things that I’ve heard perceptions that I’ve understood, I even get, I see some of the sixth exposed in social media, you know, videos that are made about how annoying families are that they’re riling the patients up. And I think a lot of it’s just a misunderstanding of what the patients are experiencing. Like I see these videos, one was, you know, doing the honking of the ventilator and family members touching the patient, and the nurse says, “Hey, don’t touch him, you’re making them react.”

But then I hold that up against survivors that are telling me, “I was so desperate to tell my loved one, ‘Don’t let them kill me, get me out of here.’ ” But yeah, there’s the nurse or any clinician saying, “Family back off, don’t connect with them, don’t touch them. Just let them lay there in peace and silence,” right?

So if we really understood what it was like for the patient, we would actually be seen, “Get in there, tell them they’re okay. Tell them their ICU, help them feel safe, help them trust us, help them understand what we’re doing for them, not just to them. Let’s hurry get the sedation off, because it’s so toxic, it’s neurotoxic, it’s gonna increase their mortality, we need you as a family member, to help keep them calm and awake as we go through this process of getting sedation off and getting them up.”

And I think sometimes, and I don’t know, if I would be the same way to if I was in this really stressful and unsure environment. My loved one is in the bed, I’m anxious to help them that I don’t know what to do. I don’t have a role. So I’m lost. And I feel like I’m in the way they’re treating me like I’m in the way. But you’re talking about very specific benefits of the family being present and roles. Communication.

Being a part of treating their anxiety being part of treating their delirium, I think they have a role, huge role in helping them mobilize, be prepared to mobilize the willing to mobilize awaking in trials, like when you have a very specific role for them, and you say, “Here is your role here, here are your duties, here’s your job description.”

They’re on it right there, like whatever it takes, if they feel valued, they’re going to be so much more cooperative with the team. I get the sense from families that when they’re kicked out of the ICU, or if they’re allowed with restricted visitation, but they’re not really involved in the process. It causes more disconnect, more anxiety, more hostility, more agitation. And I think that that’s a liability. We know that malpractice suits are less likely to happen when the families or the end of the patients have felt cared for.

`Even if things go wrong. If there’s better communication, there’s more connection with the clinicians, they’re less likely to sue them. So when you bring up family, families being part of rounds, I am a big believer, because when they don’t get to see that process of decision making, and that collaboration and what goes on behind the scenes, to care for their loved one. They’re getting this little snapshot, they’re like the nurse isn’t here because they don’t care.

Or they made a decision because they don’t care. And that just adds into this whole lawsuit. But when they’re in on those discussions, and they’re like, they value me, which means that they love and they care for my the patient, which is my loved one. And I’m hearing how they’re making decisions and why they’re making decisions. That brings in a whole different perspective for the family.

And then the clinicians don’t necessarily have to re explain everything. I’ve told families and feel free to ask questions at the end. If there are questions that they ask that are more extensive, there’s no need to take up the entire team’s time on that. But we can say, let’s definitely address that when we have our one on one meeting and talk about that more extensively. But that way they have easy answers, questions are answered.

But then they have the productive questions that we can really dive into once we get in the room. And they already are up to date and we can make those one on one meetings quicker and more productive because they were already in on rounds. So that’s what I was raised with family being in on rounds. And now I’m realizing that nobody really does that. Have you seen that happen? Have you seen families that get standardized as part of the rounds process?

Lito Rama, RN, MBA 35:03
On a standardized, I don’t think so I think one of the fear probably is like the HIPAA violation, like if the family, correct me if I’m wrong, like, you know, if the patient will allow visitors or family to be to be present. So you know, that can that can be you know, and for this research, like, we call it like liberal patient controlled liberal visitation.

So we also give like, so is, as I mentioned, either we base it on Levine’s conservation principles, so we have the personal integrity, so we give them patient control or autonomy. So they’ll be the one to determine, like, Who’s, who’s allowed to visit them. And we also incorporated like, because in my previous ICU, we have like a quiet time.

So we’re trying to get them some rest. So we asked them, like the one to have like a quiet time, or do you want to have a 24/7 visitors, that’s how we conducted this, the intervention. So like, he addresses both the social and personal integrity as well as like energy conservation and Levine’s the theory. So, I think, yeah, it covers the privacy aspect, like if they determine someone who can be present in their rounds, the one that they’re comfortable, like the decision makers, for example, if the patient cannot make decisions, then I think that can solve or address those issues.

Kali Dayton 36:32
Absolutely, yeah, this should be determined by the patient. Yeah, what’s currently happening as patients may want families there and and need them there. But that’s not even an option. But if that door is open, and we’re consulting with the patient, and hopefully you don’t know, we can walk in ICUs patients, even when they’re intubated, usually should be able to communicate and say what they want and don’t want.

They should be able to say, “I’m okay with my wife being here, but I don’t want my brother here.” You know, they can say very specifically, it’s because it’s, it’s their fight for their life, they get to determine who they want, who they don’t want, but we’re not going to be barriers to that.

Lito Rama, RN, MBA 37:12
Exactly.

Kali Dayton 37:13
They know what they need. And, yeah, they need a quiet night. And they tell us that and the family wants to stay, we need to respect the patient’s wishes most of all, but if they need their spouse there at night, we need to respect that and facilitate that. And we do Yeah. And we can ask, Is it okay, if they’re in on rounds and participate in this collaboration, decision making? And ideally do that maybe with the patient?

Depending on the ICU setup, the patient’s capacity and whatnot. But we should be involving patients in their decision making in all ways, but even especially family involvement? Yeah. Absolutely. And that’s, that’s how we preserve dignity. Exactly. They’re not out. They’re not in solitary confinement. Exactly.

Lito Rama, RN, MBA 38:01
And then they reach that distribution recognized the psychosocial needs of the patients, which, you know, as whatever she was what we often neglected, I think, for those patients in the ICU, a special one. Absolutely.

Kali Dayton 38:14
And I think our sedation practices really feed into that. It’s really easy to dehumanize patients, when they don’t respond to us when we don’t have to interact with them. On that kind of level, we don’t realize there’s psychosocial needs. Because they’re laying there still with their eyes closed, they look like they’re sleeping, and they’re not, we don’t feel like they’re involved in the process, so that those needs are really irrelevant.

It’s like you come to the ICU, the second you’re on ventilator, the spiritual, emotional, psychosocial part is left at the door. Now we’re just working on a body, we’re just focusing on the kidneys or the lungs, right. But if we’re really humanized, an ICU, we will put that back in the patient’s hands and say, “Who do you need? Who’s going to help you survive this? Or if they’re not able to provide that information to ask their closest loved one? Who was your loved one? What do they need? What is their favorite music?”

Lito Rama, RN, MBA 39:11
Yes,

Kali Dayton 39:12
You know, how do we get them going? And how do we get them focus and fighting for their lives? How does this all play into the ABCDEF bundle?

Lito Rama, RN, MBA 39:22
I think for the bundle, like as what I mentioned earlier, like assessment of pain, like if you have a family visit at a bedside like it can leave like early recognition, recognition of pain, like we can address those better. And basically, it will help like patient’s recovery.

Hopefully it’ll have better shorter length of stay in the ICU and on family engagement, empowerment, like having them involved, like as what I think I already mentioned earlier, there’s a lot of benefits and dhaoine like decreasing anxiety, decreasing psychosocial, like complications that includes delay. And probably if they’re, they’re having someone that they can easily recognize will be very, very, very beneficial for them.

Kali Dayton 40:08
Absolutely, we know that f is family engagement and empowerment. So we always say A to F, but really, it’s E and F that get left out the most. When we look at compliance with the bundle, we are much more compliant with awakening breathing trials, as far as at least charting them assessing a we start repenting on every one, and we call that the A.

But when it comes to early mobility and family, we really don’t, and therefore I don’t think we really practice the D. So it’s probably just the ABC bundle in most units, if that. But when we really focus on the F, that should be our guiding star. When when we look at what are our policies with family visitation?

When we recognize that A to F bundle on average, even with a spectrum of compliance, decreased seven day mortality by 68%. And that the units that had less sedation, more mobility, more family engagement, had a much higher rate of survival, then we’re going to see family as it is as the life saving intervention and part of evidence-based medicine.

But that’s really hard for clinicians to comprehend, right? We’re like no medicine, it’s pharmacology. But no family is medicine. And we’re practicing evidence-based medicine, gold standard of care is the A to F bundle, then we really don’t have reason to kick families out, especially when patients want and need them.

And I would say to that, you make a great point about the pain. I didn’t hadn’t even really thought about that. But they know better than we do when their loved one is in pain or what they need. But even the B for both spontaneous awakening and breathing trials, I have a really hard time with the 5am standardized the week, new trials with no family present, one are in no PT OT, in a dark room with a tired frazzled nurse trying to manage another patient while they took sedation off and the patient comes out thrashing.

One study showed that those who kind of awakened the trials actually resulted in a higher cumulative dose of midazolam. Because we rush back to the sedation, we usually turn on higher. So then what would we do? I mean, this all comes down to the RN, when we structure “the bundle”, quote, that way.

But when we’re really utilizing family, and optimizing all the power they have, then we will do awakening trials with the family. I liked your note about educating them, and preparing them saying,

“I’m going to take down sedation, they’re at high risk because of the sedation of having delirium. So that might be that come out really confused, agitated, thrashing. Your job is to talk to them, help them calm down, what do you think will help them? What’s their favorite music? Right? Yeah. Our goal is to get them upright, and work through the delirium, and have them reconnect with their environment. But they’re, they might be scared, they might think that they’re kidnapped or something bad, you are their safe place, you’re safe person, they’re safe person. So we need you.”

Right? So you, you give them all the tools so they can be really productive player in this process. And that is the B of the ABCDEF bundle is utilizing family recognizing the D of delirium, we’re going to be ready to assess it, and then treat it to not run back to sedation, the very thing that probably caused it, but we’re going to use family to treat delirium and get them out of it. And therefore help save their lives.

So if I were to do a study, looking at length of stay, I would probably have family play that kind of role. And then look at the length of stay, because if family is being used to help minimize and avoid sedation, boom, you’ve got a huge decrease in length of stay.

I think that’s but family’s there while they’re sedated and immobilized, then they don’t really have the opportunity to help change their outcomes. So we have to use family to play into the overall vision of the A to F bundle, which is to “have patients awake, engaged, cognitively active and physically active to express their needs.” That is the A to F bundle.

But unless… if we’re not trying to reach that goal, then family presence is helpful. They can know what’s going on, they can prepare their loved ones for the after the ICU, they can provide comfort even when they’re sedated. But their benefit isn’t maximized unless we are pulling the whole bundle together to get patients awake and moving. Are my thoughts but I just feel bad for clinicians that are expected to do this or expect to do waking trials, but families are kicked out. Like as a nurse, how does that impact your role when you’re having to turn sedation down

Lito Rama, RN, MBA 44:51
I think having the family like you know, I think it actually decreases your workload having someone there present.

Kali Dayton 44:57
So that is so much of my experience. Because, when you have someone that is hilarious, as a nurse, you are afraid to turn your back. I think nurses are even afraid of the rest zero if someone is confused, right? We’re as nurses, we’re hold completely liable for unplanned excavations, line tube removals, falls any of that, right, which is a whole nother discussion about how we need to structure the blame and liability.

But that’s the reality of what the way things are. So nurses are not excited about keeping sedation off when they have to go check on their other patient.

Lito Rama, RN, MBA 45:32
Yeah.

Kali Dayton 45:33
But that needs, the family members job also should be help them be distracted, help them be engaged with something else help remind them what the tube is about what’s the they don’t let them touch the tube, right. And that’s also how we avoid restraint use.

Lito Rama, RN, MBA 45:51
And I think that reorienting them, I think that’s quite simple. But I think that’s huge help if the family will be able to help us and that one leg reorient and everything they get confused. Absolutely.

Kali Dayton 46:02
And that’s, that’s really exhausting, as a nurse to have to do that your whole shift, right? I mean, it’s fine, if that’s your only task, but you have so many other things to do, you have a whole nother patient to do and you have other causes that need your help, you can’t be in the room, the entire 12 hours.

But there is someone that can probably their family member, and what they know that by being the one to reorient them to keep them safe to keep the tubes in line and place that they’re helping save their lives. Who wouldn’t be willing to do that. So I think we underestimate the power of the family, the willingness, and that when they know what is expected of them, that they can actually be huge contributors in ICU.

But we need to give them that chance in that preparation. But on the flip side, there are families that are do not have the capacity to be good contributors and the ICU. And we do have to protect our clinicians, we have to sometimes protect our patients. So what do you think about behavioral contracts? When there’s a situation that complicates things?

And so instead of making a blank policy, where you you have one bad situation you’re like, therefore, families can’t stay after seven or whatever. But if you have the exception of family, that is not being appropriate? How do we provide security for everyone else involved during that exceptional situation?

Lito Rama, RN, MBA 47:29
Yeah, I think for us like to give care to the patient, we always make sure that we’re in a safe environment, right? You feel like you have a family, I think that that is yelling or cursing. The health care workers, I think we have to set boundaries, like that behavioral contract will take care of your loved ones, but you have to behave appropriately.

Like, I think, from my experience, like at some point, like we have to, like ask a relative like, step out, and they’re basically like, you’re welcome to come back after 24 hours. But our expectation is for you to be here behave in a certain way that’s acceptable, and, you know, stop like giving, like our verbal verbally abusing the healthcare workers, because they’re basically helping a family member, senior setting those boundaries, and then basically not closing the doors for them. But having that expectation, you’re welcome to come back. But, you know, this is our expectation for you to also behave this certain way.

Kali Dayton 48:35
I like that I like the almost like the timeout, right? You have a situation. And really, if you just think about the stress that they’re under, no one’s on their best behavior. And so you could end up doing the disservice, you know, if they have a moment where they do get upset, do get worked up, and then kick them out the rest of the time, it could really cause a whole nother more traumas complications later.

But you do need to have some consequences, but also some boundaries set. So saying, “You’re welcome to come back in 24 hours here is our written contract.”

Lito Rama, RN, MBA 49:13
Yeah,

Kali Dayton 49:13
With expectations clearly defined, and have them sign it. So they agree that if they’re going to come back and 24 hours, these are the expectations of what we expect from them and how they’re going to behave and how we’re going to work together. I like that, because I think sometimes families might have a moment. I know, one family told me about she came in and her dad had had lots of complications.

He had gone to IR for a PEG tube placement had probably perforation and bled out and had an arrest and all these things that happened right? So then he’s on the med surg floor again, she walks in and his peg tube is out again. And she’s panicked. And she’s saying “What, how did this happen?”

And so she’s asking the nurse and doesn’t know the charge nurse comes in? She’s like, “No, I want to hear from the nurse who was here.” Right? So if she’s a yoga instructor, I don’t know, I can’t imagine that she was really that crazy. But I don’t know if they felt threatened defensive. Maybe she did get upset, right? Like maybe she did raise her voice.

But they kicked her out. And it’s been four months. Because she’s in the same hospital system, she has not been able to go back and see her dad except for like, one hour a week. Wow. And they won’t give her information that will talk to her. But she’s technically his POA.

So if you think about that, from an empathetic perspective, I would be panicked, too, right? Like, he almost died for having this placed. And now it’s suddenly out and no one can tell me why. Right? So just understand in that moment that that was a moment. But to say, we do want you here, but we need you to work cooperatively, don’t you know, maybe she, let’s say she was cussing and yelling, right?

“So that’s not acceptable. So you’re going to have another chance, but here are your expectations, go take a cool off for 24 hours and then come back, because we still need family at the bedside.” So I think that’s a good, that’s a good approach.

And I think everyone’s gonna have their own nuances, and they’re gonna be exceptional cases. And you might have to really restrict families period. But we shouldn’t set blank policies that prevent families from being able to do all the good that they can, because a few family families cause problems back in the past.

Lito Rama, RN, MBA 51:26
Yeah, exactly. And I think like, I’m going back, like, if we give also like the relatives, some control was like, some family members can probably like add stress to the patient, if they will visit, like, if the patient has a control, like, “Hey, this is my visitors. I just want this like five people, for example, to visit me,”.

We can, you know, better streamline those visits, and it’s still like liberal visitation, but basically, like, patient has control on who, who can come, you know, and I believe that, that place that is like the place of the best interest for the patient.

Kali Dayton 52:07
And on behalf of the clinicians, they should have one spokesperson for the family. So yeah, maybe five people are allowed to come in, those are his people, his group, and I think it’s important for them to be able to take rotations if they’re staying overnight, right. But clinician should not have to explain the same thing after the same questions over and over again. So I think upon admission to the ICU, “Who is the spokesperson? okay, you’re it, we will answer your questions.”

You know, you can answer a little things, as you know, as you go on, but it shouldn’t have to have big family meeting with all five people at different times, it’s not a good use of anyone’s time. So making those expectations clear in the comments, saying, “We’re happy to have you here, who’s the spokesperson, now you are in charge of disseminating information to your own community and family, that will not be our job. So we’ll take calls and questions from one person.”

Lito Rama, RN, MBA 52:58
I think that’s a real concern for the clinicians, like if one family member would call frequently, and then another will call them you know, like five times you have to answer a call and then explain to them like 20 minutes, like, every time, so just like ours, like being like that you can use it a bedside.

So in one of the ICUs that I worked, we like at some point like we we inform our, our relatives, “Hey, if you want an update, we usually do update around this time,” say like, like, I think we determined like around 10 to 11. Because that’s like the time where we’re not so busy.

“So we’ll give you an update on this time.” So whoever is like the point person for the family, we give them up later on that time. So in that way, like that care basically is not being disrupted. We specify the time when we give information to the patient to relatives, you know, and addresses or anxiety also.

Kali Dayton 53:56
Yep, and they exactly addresses anxiety, they know what to expect, they know they’re going to get information, they don’t feel like you’re putting them off. It just helps everyone be on the same page. Yeah, so as we hopefully move forward with more liberal visitation, we can also create a structure in which everyone understands their role, how to work collaboratively together, how to be appropriate and how to make everything patient centered.

Lito Rama, RN, MBA 54:23
Exactly.

Kali Dayton 54:24
Thank you so much for your wonderful publication citations, again to all of these studies that you’ve mentioned will be on the transcription please check them out. Please advocate for your patients to be able to have the power of the family at the bedside when whenever they need it. Not just for the few hours a day that we’ve been doing it COVID is not totally over. But it’s time to learn from the COVID crisis and move forward to true master the ABCDEF bundle. Thank you so much, Lito.

Lito Rama, RN, MBA 54:53
Thank you. Thanks a lot.

Transcribed by https://otter.ai

 

Resources

What do we know about the history of family visitation in the ICU?

• historically restrictive

> Traditionally – restrictive to control infection (Haghbin, 2011)

> majority is restricted, USA (Lee, 2007)

> All ICUs in Belgium are restricted (Berti, 2007)

• Opened up in the 2010’s

> study Fumagalli (2006) – no direct infection risk for patients and reduced cardiopulmonary complications with more vistiation

> American College of Critical Care Medicine Task Force recommended Liberal Visitation (Davidson, 2007)

> followed by the AACN – (Bell, 2011)

> British Association of Critical Care Nurses (BACCN)  (Gibson, 2012)

> 94.8% restricted, 606 hospitals (Liu, 2013)

> <20% has liberal visitation, 133 Pathway + 404 Magnet facilities (Milner, 2019)

> Liberal visitation is more common in ICUs in <150 bed hospitals

> OUTSIDE USA:

> Belgium – still 100% restricted (Vandijck, 2010)

> UK – 80% restricted (Hunter, 2010)

> Netherlands – 90% restricted (Noordermeer, 2013)

> Brazil – 2.6% liberal visits (Ramos, 2014)

> evidence family presence during CPR is not disruptive (Mara, 2017)

> RNs (6 studies between 2006-2014) – negative perception of nurses to liberal visitation, disruptive to patient care (Patient Centered approach, set boundaries, privacy, family meeting, set time when to give updates, ICU rounds family can be there if patient consents)

– Kean & Mitchell (2014) UK & Australia

How does this play into the ABCDEF Bundle?

> Assess and manage pain- presence of family can lead to early recog pain

> F – Family Engagement and Empowerment (Pun, 2019)

How can we work more harmoniously with families?

> McAdam (2008) – family – unrecognized and undervalued

> active presence, patient protector, facilitator, historian, coach, voluntary care givers (oral care)

> interpreters (Fumagalli, 2006; Errasti, 2012)

> absence of family is attributed to psychological symptoms in ICU (Moss, 2011)

Citations

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