Stakeholders' views and recommendations on active participation of family members in direct ICU care: A qualitative study.

As patients, hospitals, and the scientific community deal with the rapidly evolving effects of the coronavirus disease 2019 (COVID-19) pandemic, nurses have been called on to respond quickly and in many roles. Direct patient care is undeniably an international, national, and local priority. Yet as we deliver that care, many clinical questions arise about how we, as frontline caregivers in a time of crisis, might "do it better." For example, evidence regarding COVID-19 indicates the importance of frequent handwashing, maintaining a safe distance from others, and avoiding touching our faces, but how are we modeling these evidence-based behaviors for patients and their families? What is the best way to provide care in accordance with the new worldwide rules and regulations regarding personal protective equipment? How are we compassionately communicating with the loved ones of patients who are hospitalized while enforcing enhanced visitation restrictions for the safety of all?Many new approaches are emerging, from both the lay press and the scientific literature, for achieving high-quality care and communication in the context of restricted visitation. We, as nurses—some of the most trusted members of the health care team1—are called on to deliver care that reflects the best scientific evidence. Doing so involves not only living out the daily rigor of providing care but also using our skills, creativity, and ingenuity to develop ideas for clinical inquiry, to study what we are doing and how we are doing it, and to determine in the midst of a crisis how to measure the care we provide in order to make it even better.The purpose of this column is to describe the planning and implementation of one such initiative and to share how thinking quickly and accessing critical resources can together produce strong clinical inquiry, even in times of duress. Our team identified the clinical problem of how to deliver high-quality, effective communication with families in the context of visitation restrictions. Here we describe, as a case in point, the project "Use of Video Chat to Facilitate Communication between the Healthcare Team and Loved Ones in the Intensive Care Unit" to emphasize the process of developing a clinical inquiry during a short time frame.For patients' families and loved ones, and often patients themselves, the experience of the intensive care unit (ICU) can be isolating.2 The inability of significant others to be physically present in the ICU can cause isolation, which can contribute to worse patient outcomes, including depression, anxiety, and delirium,3, 4 and is often exacerbated by sporadic communication from the health care team.5 Because of the isolation imposed by COVID-19, health care organizations have quickly transitioned from open visitation policies, which improve patient outcomes and communication between the health care team and patients' loved ones,6–8 to fully restricted visitation. The drastic change in visitation policies was imposed with little forewarning, thereby limiting transparency, contributing to anxiety among patients and families, and compounding stress for patients, their loved ones, and clinicians on the health care team. The ICU team at our institution was challenged to identify innovative methods that would promote effective communication and patient- and family-centered care while maintaining a consistent workflow.Evidence was lacking in the literature for optimal communication strategies in the context of restricted visitation.4 Although electronic tablets and smartphones have been used for more than a decade to educate patients9 and plan the discharge process,10, 11 and although their use has been studied in educational initiatives implemented before and after procedures and after discharge,12 most clinical inquiry related to these devices was limited to education. The acute care literature contains few studies of the ability of smartphones or texting interventions to improve communication or provide a virtual sense of presence between a family, their loved one in the ICU, and the team of health care providers entrusted with the patient's care. Scientists in Denmark reported that the use of technological devices for communication demonstrated benefits for patients but had deleterious consequences on clinicians' workflow processes.13Communication-focused studies conducted in the ICU setting reported that patients most value the timing, frequency, and content of communication.5 The most salient of these studies, published by Seaman et al,5 was not conducted in a restricted visitation or isolation scenario. Among those researchers who studied non-ICU settings, a French-Canadian team reported, measured, and validated the concept of telepresence, or the ability of a technology to establish a sense of one's physical and social presence at another location, as an effective means of communicating virtually.14 Beyond simply teaching or exchanging daily numbers in a status report, telepresence holds the hope of achieving much more— establishing and building trust, compassion, and care in a situation imbued with concerns, anxieties, and fears that are potentially unique from those typically faced during an ICU experience.13Using evidence that electronic tablets could be applied successfully to educate patients and help plan discharges,9 our workgroup evaluated their use in allowing virtual visitation and communication in the ICU. We designed a clinical inquiry project to address the diminished sense of family presence in the context of restricted visitation and ensure accurate and timely communication between patient's loved ones and their health care team. Specifically, we sought to address 3 questions: (1) Is the use of an electronic device to facilitate virtual visitation in the ICU satisfactory for patients and loved ones when in-person visitation is restricted? (2) Are the advantages of electronic tablets (video plus critical information exchange) perceived by patients and loved ones to be superior to those of telephone alone (critical information exchange only)? (3) Are the costs of electronic tablet use (initial investment in devices, maintenance costs and upgrade fees, time nurses spend initiating and facilitating interactions) offset by benefits in patient and family satisfaction and in the effectiveness of communication, thereby justifying more generalizable, long-term use?The resources needed to facilitate video chat as a method of communication were not readily available in our setting. On the day that a strict no visitation policy was implemented, the ICU team at our institution requested from the hospital's incident command center the devices and technological support to pilot video chat in 2 ICUs. The leadership team approved the request the same day. Because technological support is a fixed resource within the organization, the ICU team accrued only the costs for the devices. A workflow and protocol for the video chat process were not readily available either, so the ICU implementation team, which consisted of 2 nurse leaders (MK and KK) and 2 hospital administrators (MM and MC), created them. Bedside nurses, advanced practice providers, and members of the Patient Family Advisory Council were also included in developing the workflow and tools to assess process measures.Last, the role of "facilitator"—the team member who would support the consistency of and follow-through on the day-to-day work associated with telecommunication and data collection—was identified as a gap. This role was proposed, approved, and implemented within the week. In anticipation of capacity issues related to COVID-19 cases, the Duke Heart Center ICUs postponed elective admissions to the ICUs. This decrease in ICU census freed up 2 nurses for 12 hours a day, 7 days a week to fulfill the facilitator role.In addition to the rapid changes in the clinical setting, the challenge of rigorously evaluating the proposed solution required a rapid response. The pace at which the work needed to be designed and implemented required the clinical team to engage partners from the university–health system partnership in order to prioritize a review of literature to identify tools and optimal study designs. In addition, the partnership provided expertise for efficiently creating a formal study design and expediting the institutional review board approval process. The university–health system partners identified an appropriate study design and a process for analysis, and they facilitated the selection of a validated instrument for measuring end points.Electronic tablets were approved for deployment in 2 ICUs: a 17-bed cardiac ICU and a 32-bed cardiothoracic surgical ICU. Preparing the units for implementation and preparing the devices to receive video calls required time, nursing workflow expertise, and administrative support.The first phase of decision-making addressed the most feasible video chat application to use. FaceTime and Zoom were the most user friendly and supported various cellular phone carriers; thus the team decided to pilot the process with these 2 applications. The 2 hospital administrators on the implementation team led efforts to simplify the technology for the end users. In addition, a device-cleaning process was established on the basis of evidence from a previously approved protocol for cleaning electronic devices.9A second, concomitant phase of activity was creating a workflow and documentation process that was flexible but could meet the goal of providing consistent communication between the health care team, patients, and their loved ones. The 2 ICUs and their respective patient populations required unique workflows because patients in cardiology medicine and patients in the postoperative phase have different communication needs. The team created 1 workflow to support both patients scheduled for ICU admissions (eg, those preparing to undergo a surgical procedure) and patients with unplanned admissions to the ICU, including those from the emergency department or being urgently transferred from referring hospitals or step-down units, or directly from their homes (Figure). The detailed workflow noted the timing and frequency of the use of multiple documents including staff training and education tools, communication scripts, and patient intake forms designed to capture data on patient preferences and the structure, processes, and outcomes inherent to improving communication in the context of ICU visitation restrictions related to COVID-19.Our team developed a virtual visitation communication tool to support consistent collection of data from patients and their loved ones, and from health care team members. Clinicians used section 1 of the tool to document intake information from patients who were scheduled for admission in order to identify the patient's primary contact person and their contact information. It also introduced the patient to the ICU communication plan. Section 2 was developed for the initial communication between the health care team and the patient's primary contact person. If the patient's ICU stay was longer than 24 hours, the facilitator was to contact the primary contact person and complete section 3 of the tool, which includes a script and questions related to the electronic devices used by the primary contact person and their preferred method of communication. Clinicians also completed a daily communication log to document ongoing interactions. Once the patient was ready for transfer to a stepdown unit, the facilitator completed sections 4a and 4b of the virtual visitation communication tool (Table).A nurse on each unit filled the role of facilitator, which was designed to support consistent daily communication between the patient, their loved ones, and the health care team, and to collect the data required in order to measure and evaluate the newly designed workflow processes and outcomes (described in the next section). Although this role was considered optional and not required for the initiative to succeed, it provided a consistent, dedicated resource to ensure that loved ones' expectations were being met regarding contact with the patient and the health care team.13 The facilitators ensured that data were consistently captured from patients, their loved ones, and health care team members and then integrated into the communication processes. They also promoted the timely and consistent collection of data and allowed for quick turnaround on any adjustments or updates to the protocol.Identifying outcome measures and defining methods for evaluation were critical aspects of the work that were supported by resources from the university–health system partnership. Despite the urgency imposed by the COVID-19 pandemic, quickly identifying evidence-based outcome measures and feasible approaches for analyzing data captured during the video chat intervention was critical to determining the ultimate success of the intervention. Thus our team used the opportunity afforded by the atypical circumstances surrounding COVID-19 to maximize the contributions from quality scholars (doctors of nursing practice), clinical nurse scientists, statisticians, and data management experts in order to address and solve the unprecedented challenge of measuring and analyzing the impacts of rapid clinical redesign on patient care outcomes.We designed a data source table around the newly created workflow to verify the accuracy and completeness of data captured at each end point. In addition, we designed analyses to evaluate preliminary data, which would ensure the reliability of documentation for measures established to capture patient-centered telepresence, communication workflow processes, and the cost and utilization outcomes associated with the clinical inquiry project. We selected key evidence-based indicators to evaluate each phase of care delivery and the associated quality of communication processes and outcomes; we assembled these indicators on 1 case-report form to make data entry easy and efficient (Table).To optimize efficiency, we selected a minimal set of questions for each phase of care. The effectiveness of video chat; assessment of loved-ones' awareness of, understanding of, and inclusion in the plan of care; and engagement of the health care team in communicating decisions each were defined on a single form, but we paid particular attention to maintaining the integrity of their respective validated response scales (Table). To evaluate the effectiveness of communication through video chat, we included 6 questions from 2 subscales using a visual analog scale. We included 3 items using Likert scales and several with binary or open-ended narrative to evaluate the inclusion of patients' families in health care decisions (Table). Each indicator and the level of measurement for each of the selected data elements then were included in the analysis and reviewed by the statistical team for accuracy.Overall, the project provided an opportunity to measure and test the quality of care delivery by applying existing evidence to the innovative use of proven approaches for solving complex patient and care-delivery problems under new circumstances and in new settings.Rapid staff education and training, and rapid initiation of the new workflow were required because of the pace in which the change occurred from open visitation to no visitation. We engaged unit stakeholders including nurses, advanced practice providers, and intensivists. The first educational goal was to address the rationale for streamlined communication and the priority to involve loved ones in a patient's plan of care in the ICU. We developed training modules to allow clinicians to role-play the communication script and allow staff to practice talking points. Next, using the teach-back process (a skill-based educational strategy), we taught team members the proposed workflow for using the electronic tablet to communicate with patients' loved ones and shared the key responsibilities of each stakeholder on the team. We introduced the role of facilitator; it was favorably received as a means of minimizing the burden for the team members providing direct patient care. Last, each group had an opportunity to ask questions and provide feedback. The workgroup worked through mock communication scenarios to test the workflow and confirm that the proposed process worked well.Overall, we created the design; developed the structures, processes, and outcomes; and performed the final steps of staff training, institutional review board approval, and implementation in less than 10 days. This demonstrates that teamwork, collaboration, and creative engagement of people and resources across clinical, administrative, and academic partnerships can allow workgroups to efficiently conduct evidence-based clinical inquiry projects within short time frames.The COVID-19 pandemic has introduced opportunities for rapid innovation and creativity that help to maintain high levels of care for patients and their loved ones. Because of the need for fully restricted visitation, our clinical team engaged members of a university–health system partnership to evaluate the use of electronic tablets to facilitate virtual visitation in the ICU. By thinking quickly and engaging stakeholders, our team swiftly implemented virtual visitation in 2 ICUs, providing patients' loved ones virtual access to the patient and the health care team.

Families’ perspectives of participation in patient care in an adult intensive care unit: A qualitative study

How decisions are made and communication is handled are essential to ensuring a good outcome.In the case of Scardoni v Hawryluck,1 Mrs H was an 81-year-old woman with advanced Alzheimer disease, cardiovascular illness, and septic shock whose family and physician could not agree on goals for care, requiring that a legal decision be made regarding the level of care to be provided. Over time and after much discussion, the multidisciplinary team on the intensive care unit (ICU) reached a consensus that intensive care for Mrs H would not improve her condition. So it was decided that after Mrs H was stepped down to a general medical unit, should an infection or respiratory distress develop, she would not be returned to the ICU. The attending ICU physician informed the family that instead of ICU care, “the hospital would offer her palliative care: painkillers and sedatives to keep her comfortable while her afflictions took their course.”2 In this particular case, the patient’s family challenged the health care team’s recommendations and insisted that their mother be readmitted to the ICU so that aggressive life-sustaining treatment would continue.This case, although Canadian, is relevant to ICU settings throughout North America. The purpose of this discussion is not to provide an in-depth ethical analysis, but rather to use the case of Mrs H to characterize one type of health care situation that clinical ethicists could help facilitate. Medical recommendations such as those involved in the care of Mrs H are made to prevent the “revolving door” patient, who according to ICU teams will receive no medical benefit if returned to the ICU. Decisions not to readmit are euphemistically referred to by some ICU staff as the “one-way ticket out of ICU” or “celestial transfer.” Such language shared between colleagues reflects a coping strategy, a “gallows humor,” intended to manage difficult feelings like sadness, anger, grief, sympathy, or moral distress. Cases like that of Mrs H are of particular concern to critical care nursing. Research has indicated that moral distress, a significant contributing factor to burnout, is encountered by ICU nurses when the care they are providing to a patient is regarded as futile.3It is not uncommon for hospital-based clinical ethicists to receive a request for consultation when disputes regarding similar recommendations for care arise between substitute decision makers and the ICU treatment team. These cases can lead to moral distress because of commonly held opinions among team members that futile treatment is being provided. Although staff can provide many life-sustaining treatments to such a patient, ethical questions often arise during the patient’s stay in the ICU. What ought to happen when an ICU team decides that a patient should be transferred to a general medical unit to receive comfort measures only, with no readmission to the ICU? Although teams discuss the practical questions about what can be done, the ethical questions about what ought to be done are sometimes not as clear. The following discussion explores how clinical ethicists can provide valuable assistance with the kinds of ethical challenges these situations customarily present. Particular emphasis will be placed on working within a process-driven, interdisciplinary framework that maintains a communication-oriented approach to ethical decision making.Clinical ethics is a relatively new field, and the role and purpose of clinical ethicists can vary somewhat according to the particular health care setting. For the purpose of this discussion, the authors describe the knowledge, skills, and activities of clinical ethicists through their review of relevant literature as well as their own training and experiences as staff clinical ethicists at 2 acute care settings in Ontario, Canada.Greater legal clarity or legislative measures to specifically address conflicts that arise over withdrawal or withholding of treatment for terminally ill patients are required, according to at least one legal expert. Current Canadian law, according to this same scholar, leaves doctors, patients and their families in a “grey zone” as to who should have ultimate authority on such decisions.4 The daily reality in most North American ICUs is that this gray zone persists—for better or worse. Although hospitals attempt to provide guidelines for addressing conflicts such as the one involving Mrs H, it is the quality of communication and relationship within the interdisciplinary team and between the treating team and the patient’s family that has a marked influence on decision making.5–7 In most cases similar to this one, consensus about level of care is first achieved by the interdisciplinary team, and a subsequent agreement is reached between the treatment team and the patient’s substitute decision maker and family. However, when agreement cannot be reached because of irreconcilable notions pertaining to what constitutes benefit to the patient and what constitutes harm, the results can be uncertain, stressful, and most unsatisfactory for both the health professionals involved and the patient’s family. This combination of an unfortunate turn of events for the patient, sharing of bad news with family members, and the recommendation for care outside of the ICU is a juncture of decision making at which conflict can occur and ethical challenges are most apparent to members of the interdisciplinary team.8,9Much has been written about the difficulties in communication within the ICU and how this affects patient care. Considerable evidence indicates that communication between the ICU team, patients, and patients’ families can be inadequate, leading to conflict and a possible long-term effect on the patient’s family.6,8,10,11 In one study,8 46% of families who had a loved one die in the ICU reported conflict over decisions to withdraw or withhold life-support measures. These family members also reported conflict over the manner in which staff communicated with or behaved toward them. The authors of that study8 cited family members who felt pressured by staff to “hasten their loved one’s death because they placed a burden on valued resources.” The importance of communication between treatment teams and patients and patients’ families cannot be overstated. In addressing the difficulties and deficiencies that have been identified, 2 experts concluded, “communication with caregivers is consistently identified as the most important and least achieved factor in patient/family satisfaction surveys.”12Intensive care is primarily intended to provide maximum benefit to those patients who are likely to recover from their infirmity or trauma.13 When the interdisciplinary team is not clearly communicating ethical considerations as well as the criteria they are using to determine the effectiveness or success of the treatment plan, patients’ families may develop erroneous expectations that life-sustaining interventions will continue to be offered.6 At the same time as a loved one is receiving ICU care with a grim prognosis, families are struggling to come to terms with impending loss. Family functioning or experience in coping with loss,14 unrealistic expectations regarding health outcome, within a societal context of diverse religious or cultural beliefs, can markedly influence families’ decision making about end-of-life care. Such formidable contributing factors further emphasize that effective communication strategies, as well as an appropriate level of sensitivity, ought to be used in ICUs when dealing with patients’ families.11Team communication, in particular communication between disciplines, also has proven problematic in decisions about end-of-life care in the ICU. Critical care nurses have cited difficulties in communication and decision making within interdisciplinary ICU teams. Ferrand et al15 reported that 75% of the nursing staff who participated believed that “collaboration was inadequate during decision making” despite general agreement that such team collaboration is necessary and desired. In another study,16 about one-third of the ICU nurses who participated felt “excluded by physicians from patient care decisions and felt their exclusion to be a detriment to patient care.”In terms of the burdens carried in making decisions about end-of-life care, some evidence suggests that physicians and nurses experience equal burdens. Physicians experience the burdens associated with having to make these decisions, and nurses feel the burden of having to carry out care decisions made by someone else.17 Given the shared burdens that members of the interdisciplinary team face, as well as the reported difficulties in end-of-life care decision making in the ICU, ensuring effective communication is a key feature of high-quality patient care.7 The following discussion is intended to demonstrate how clinical ethicists can be supportive of such strategies for effective communication and decision making.Medical recommendations like those pertaining to the care of patients such as Mrs H are based on best-practice standards of care and are informed by ethical principles like beneficence, nonmaleficence, and autonomy. Continued life-sustaining support in situations where benefit is in question can be regarded as futile, a concept with inherent ethical challenges. As Weijer et al18 point out, the values inherent in medical futility arguments often confuse treatment considered ineffective and treatment that will be effective but will ultimately result in a controversial outcome such as permanent unconsciousness. A team’s decision to not readmit a patient for ICU care can be an attempt to address futility based on controversial outcomes that the team may perceive as causing more harm for the patient than good. Poignantly stated, “if the welfare of the patient is the whole purpose of providing treatment and if that treatment brings needless suffering, then the whole purpose of medicine is defeated.”19 Although the concept of futility in ICU care is a subject worthy of ethical debate, it will not be the focus of this discussion. Rather, the subject of this discussion is the role of clinical ethicists in helping decision makers address ethical considerations such as futility.The results of inadequate communication, misunderstandings, or disagreements arising from divergent views about what is beneficent and the institutional realities surrounding resource allocation can be seen in the moral distress and subsequent moral residue experienced by both the patient’s family members and the health care staff involved. Moral distress occurs when a person can identify the ethically appropriate course of action, but does not feel able to carry this action forward because of barriers that may include lack of resources, legal limits, institutional obstacles, or imbalances in power, for example. Effects of moral distress on an individual can include feelings of anger, frustration, anxiety, or depression.20 Moral residue can be encountered when “deeply held beliefs, values and principles” are set aside at the expense of one’s personal sense of integrity.21 For families of patients, moral residue can manifest in lifelong memories about difficult health care experiences.The experience of moral distress and moral residue are of particular importance to critical care nursing. Some evidence indicates a relationship between an ICU care nurse’s perception of providing futile care, inadequate communication about the care plan within the interdisciplinary team, and the incidence of moral distress, emotional exhaustion, and burnout.3,16,22 Cases like that of Mrs H can present these kinds of challenges to nurses providing care at the bedside. The discussion also highlights how clinical ethicists can assist interdisciplinary teams in addressing ethical challenges that can lead to moral distress.Finally, the ethical climate within our health care settings is shaped by the organizational values inherent in hospital policies, approaches to handling conflict, allocation of human and material resources, the daily-lived experience of staff providing care, and those to whom care is provided.23,24 Economic constraints, resource allocation difficulties, and staffing shortages contribute to the moral climate of health settings, the moral distress of staff, and burnout among health care providers.25,26In cases such as that of Mrs H, the ethical challenges are not just about treatment requests considered inadvisable but also about scarce resources like ventilator-equipped beds in ICU settings. In the minds of some families, the need for an ICU bed is the primary reason that palliative measures are now being recommended. When conflict surrounds decisions about level of care, it is the bedside ICU nurse who fields the questions, concerns, and emotions expressed by patients’ families.It is through such challenging decision making, in which no agreement is reached, that the moral climate is regrettably defined for all persons with a stake in the decision. However oppressive these disagreements feel to both health care professionals and patients’ family members, most often the disagreements, ironically, do not result from a lack of good intentions on either side of the debate. Rather, these circumstances reflect the complex ethical challenges that are inherent in contemporary health care settings. Clinical ethicists can be an important resource to health care teams, patients, and patients’ families in addressing these difficult challenges.Clinical ethicists who provide consultative services may be requested by the ICU team when conflicts such as the one surrounding the planning of Mrs H’s level of care arise. What are the characteristics, skills, and knowledge that make clinical ethicists a useful resource in helping to address conflict over decisions about level of care for stable but critically ill ICU patients?Clinical ethicists come from a diverse background of training: clinical and academic experiences that include but are not limited to medicine, nursing, social work, theology, philosophy, and anthropology. Most clinical ethicists have advanced academic degrees and/or training in clinical ethics. Despite this diversity in background, clinical ethicists engage in common functions: consultative services, research, education and the development of policies pertaining to patient care and organizational ethics.27–29Clinical ethicists are trained to view ethical problems within an interdisciplinary health care environment whose primary commitment should always be to provide the best patient care possible. Patient care and goals for care are best understood through the wishes, beliefs, and values of the patient and the patient’s family. The approach taken by clinical ethicists in providing consultation is to model interdisciplinary collaboration and effective communication with patients and their families, with the objective of enhancing ethical decision making.28–30In effect, clinical ethicists in cases such as the one involving Mrs H act as facilitators of communication and decision making about goals for care, while directing attention to the ethical considerations underlying such decisions. Generally, clinical ethicists can help clarify differences in the way ethical considerations such as sanctity or quality of life are valued on the basis of religious, personal, or cultural values. Some evidence suggests that ethics consultation generally has been useful in preventing or resolving conflicts, and in reducing the incidence of prolonged controversial treatment.31,32 Current trends in the training and education of clinical ethicists have emphasized skills, knowledge, and expertise better suited to provide ethics support in real time as dilemmas and conflict around decisions related to patient care unfold.28What is particularly important about the approach used by most clinical ethicists is the emphasis placed on fair and just processes for decisions of such importance and consequence in an ICU environment.In cases such as the one involving Mrs H, it is not just what decision ought to be made that is of interest to clinical ethicists, but if and why a particular decision is ethically defensible. If so, to whom is it ethically defensible? How ought discussions and conflicts be managed? These questions raise ethical concerns about justice, fairness, and a reasoned approach to decisions of such consequence. Ethical consideration must also be given to the moral climate, how people feel treated, and the concerns and opinions of key persons with a stake in the decision making, with overarching consideration given to trust in the process used to make such important decisions. Therefore clinical ethicists are as concerned with procedural fairness as they are with outcome when assisting with ethically challenging situations in health care settings.Principal aspects of procedural fairness are as follows: that the process for decision making be as transparent as possible to all involved; that concerns of key persons with a stake in the decision making be considered; that the reasons or rationale behind decisions can be understood and defended; that people responsible for decisions be held accountable; and that in the event disagreement occurs, decisions can be reviewed, taking into account the concerns of those who disagree.33 Process-driven approaches to decision making or to resolving conflict used by clinical ethicists are dependent on using frameworks to guide communication. Such frameworks for communication are not just ethically defensible; they have been shown empirically to be part of good practice standards in ICU settings.6,11,34 Lilly et al35(pS398) found that using a standardized framework for communication resulted in health care providers seeing decision making as a “process rather than as an event”—an attribute consistent with principles for ethical decision making.An example of such a framework to guide communication is described by Lautrette et al,34 who identify such attributes as timeliness, opportunities for the patient’s family to speak, use of appropriate and sensitive language, and ensuring that the setting is private and comfortable. In addition to these attributes, clinical ethicists would include discussion of the values in conflict and ethical obligations that underscore decision making.Frameworks for communication appear well supported in the literature anyway, so what makes the involvement of clinical ethicists of added benefit?Despite advances in implementing communication strategies in many settings, improvement in general is needed in managing communication, enhancing understanding, and meeting needs of ICU patients and their families.6,8,10,11 Furthermore, Sherwin36 believes that communication frameworks and hospital policies can be used coercively, to enforce a particular outcome, if those who lead these discussions or who adhere to policies are not reflecting on personal biases, institutional pressures, and ethical considerations.Clinical ethicists act as facilitators, helping to raise important ethical questions, model effective communication, and model ethical decision making by using teachable moments to heighten the awareness and understanding of the ethical considerations in each case. Within most health care settings, necessary and unavoidable imbalances in power are present between various persons who have a stake in the decision making. Clinical ethicists assist in discussing the values that underlie decisions of such importance, making these transparent to and understood by key involved parties. They model the principles of procedural fairness. Inherently challenging decisions about level of care, as in the case of Mrs H, are often met with challenging feelings and opinions, making fairness and ethical reflection more important than less to involved parties.Clinical ethicists advocate for policies and practices that reduce coercive consequences that can arise when members of the ICU treatment team, patients, or patients’ family members feel overruled or dismissed. In conducting an ethics consultation, the clinical ethicist leads discussions with the interdisciplinary team members about ethical considerations that contribute to moral distress, for example, the conflict in the way benefit and harm associated with a particular therapy or level of care are understood. In most instances, the clinical ethicist must ensure that concerns raised by members of the interdisciplinary team and concerns expressed by patients’ family members are shared and considered. This process is handled in an open and transparent manner. In creating an opportunity through the consultative process for the interdisciplinary team to address concerns, related to both areas of conflict and moral distress, clinical ethicists are also capitalizing on valuable teachable moments in which knowledge about ethics and decision making can be enhanced. As Kälvemark Sporrong et al37(p835) concluded, “Ethical competence is a key factor in preventing or reducing moral distress.”We have found that consultation on an individual case often helps treatment teams identify preventative strategies to reduce or avoid conflict and to engage in more timely discussion about ethics the next time a complex care situation arises. Such measures are necessary in creating a moral climate in which discussion about ethics in daily practice can be supported and thus reducing the effects or incidence of moral distress. The potential exists for all members of the interdisciplinary ICU team, including the most responsible physician, to be so engaged in ethical reflection and decision making on challenging cases. Clinical ethicists model skills of effective communication, ethical reflection, and decision making as well as principles of procedural fairness within the consultative process that they facilitate.We are not suggesting that effective communication, procedural fairness, ethical reflection, and decision making are deficient whenever clinical ethicists are not involved in such cases. In reality, complex and ethically challenging cases occur routinely in ICU settings, most often without the involvement of clinical ethicists. What is being proposed is that clinical ethicists should be seen as a valuable resource for addressing challenging cases in the ICU. Better understanding is needed about the role of clinical ethicists and the kinds of assistance they can provide.In most cases, the ICU team and patient’s family agree on recommendations that comfort measures be provided on a medical intermediate care unit or a palliative care unit for a stable but critically ill patient. However, as in the case of Mrs H, these decisions may be met with considerable emotion from the patient’s family and with differences of opinion about benefit and the appropriate level of care. We think that clinical ethicists can be a valuable resource when challenging cases arise. By providing consultation, clinical ethicists can model effective communication, ethical reflection, and decision making, while following principles of procedural fairness, all of which are key elements to upholding ethics in daily practice and are of particular importance when conflict occurs about level of care in the ICU.The following are practical considerations for critical care nurses:

Background: Estimates of contamination of healthcare personnel (HCP) gloves and gowns with methicillin-resistant Staphylococcus aureus (MRSA) following interactions with colonized or infected patients range from 17% to 20%. Most studies were conducted in the intensive care unit (ICU) setting where patients had a recent positive clinical culture. The aim of this study was to determine the rate of MRSA transmission to HCP gloves and gown in non-ICU acute-care hospital units and to identify associated risk factors. Methods: Patients on contact precautions with history of MRSA colonization or infection admitted to non-ICU settings were randomly selected from electronic health records. We observed patient care activities and cultured the gloves and gowns of 10 HCP interactions per patient prior to doffing. Cultures from patients’ anterior nares, chest, antecubital fossa and perianal area were collected to quantify bacterial bioburden. Bacterial counts were log transformed. Results: We observed 55 patients (Fig. 1), and 517 HCP–patient interactions. Of the HCP–patient interactions, 16 (3.1%) led to MRSA contamination of HCP gloves, 18 (3.5%) led to contamination of HCP gown, and 28 (5.4%) led to contamination of either gloves or gown. In addition, 5 (12.8%) patients had a positive clinical or surveillance culture for MRSA in the prior 7 days. Nurses, physicians and technicians were grouped in “direct patient care”, and rest of the HCPs were included in “no direct care group.” Of 404 interactions, 26 (6.4%) of providers in the “direct patient care” group showed transmission of MRSA to gloves or gown in comparison to 2 of 113 (1.8%) interactions involving providers in the “no direct patient care” group (P = .05) (Fig. 2). The median MRSA bioburden was 0 log 10CFU/mL in the nares (range, 0–3.6), perianal region (range, 0–3.5), the arm skin (range, 0-0.3), and the chest skin (range, 0–6.2). Detectable bioburden on patients was negatively correlated with the time since placed on contact precautions (rs= −0.06; P < .001). Of 97 observations with detectable bacterial bioburden at any site, 9 (9.3%) resulted in transmission of MRSA to HCP in comparison to 11 (3.6%) of 310 observations with no detectable bioburden at all sites (P = .03). Conclusions: Transmission of MRSA to gloves or gowns of HCP caring for patients on contact precautions for MRSA in non-ICU settings was lower than in the ICU setting. More evidence is needed to help guide the optimal use of contact precautions for the right patient, in the right setting, for the right type of encounter.Funding: NoneDisclosures: None

You have accessThe ASHA LeaderFeature1 Jun 2011Productivity in Audiology and Speech-Language Pathology Kyle Dennis andPhD, CCC-A Stephen A. GonzenbachEdD, CCC-A/SLP Kyle Dennis Google Scholar More articles by this author , PhD, CCC-A and Stephen A. Gonzenbach Google Scholar More articles by this author , EdD, CCC-A/SLP https://doi.org/10.1044/leader.FTR2.16062011.16 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In http://www.asha.org/Publications/leader/2011/110517/Productivity-in-Audiology-and-Speech-Language-Pathology.htm As health care dollars grow increasingly tight, health care organizations must focus on being more concerned about accountability and efficiency. Accordingly, in member surveys ASHA has tracked the requirements for productivity—defined as the number of hours in direct patient care divided by the number of hours worked. In the ASHA 2009 SLP Health Care Survey, for example, 59% of respondents (n=1915) reported their facility had a productivity requirement. The ASHA Care Survey Report: Workforce and Work Conditions Trends, 2005–2007, showed that in 2007, as in 2005, most respondents indicated that their facility had a productivity requirement (60% and 61%, respectively). Productivity models are an effective way for audiology and speech-language pathology programs to examine how efficiently they provide services (not merely counting the number of services they perform). Some basic principles of productivity are particularly applicable to hospital settings. Productivity Factors Several factors influence productivity, including: Complexity. Complexity of services affects productivity because of the amount of time it takes to perform services. In addition, the type of service performed (e.g., diagnostic services, treatment services, or aftercare services), age of patients, and type and severity of communicative disorders also affect the complexity of clinical services, and consequently the number of services that can be performed and the time required to perform them. Staffing. The availability of professional and support staff greatly affects productivity. Although large clinical staffs tend to generate more patient visits, they are not necessarily more efficient in service delivery. For example, a clinic with clerks and assistants may be more productive than a clinic without such support because clerical and technical activities have to be performed by the professional staff. Assistants free the clinician to concentrate on more complex procedures, which typically require more time. Clinic Space and Equipment. A clinic can perform procedures only when equipment or space is available. The availability of space (e.g., exam rooms, sound suites, and special procedure rooms) and equipment limits the patient flow through the clinic. On-duty Hours, Leave, and Non-clinical Duties. On-duty hours and leave (e.g., vacation, sick days, personal days) affect time available for direct patient care. For example, a clinician could be assigned duties other than direct patient care (e.g., administration, mentoring, or research). This time is productive from the standpoint of clinic operations, but it does not generate direct patient care hours. Coding Systems. Coding systems affect productivity if they do not capture all of the services the clinic provides. Ideally, there should be a procedure code for every service performed. In reality, code systems such as CPT (Common Procedural Terminology, © American Medical Association) do not capture all audiology and speech-language pathology services. For example, audiologists and speech-language pathologists may not be able to capture professional services such as decision making, care planning, coordination of care, counseling, team management, and device handling. Coding systems designed for reimbursement (billing) also may not capture non-covered services. As a result, these systems may actually undercount productivity because some professional services will not be included. Labor Mapping. Because the work day typically involves time dedicated to direct patient care and other professional activities that are important to the function of the clinic but do not generate direct patient care hours, labor mapping is a useful way to allocate time during the work day. Labor can be allocated to the following areas: Direct patient care—Time devoted to prepare for, provide for, and follow-up on patients’ clinical care needs. It includes time spent rendering care to patients (pre-, intra-, and post-service), care coordination, documentation, continuing education, and staff meetings focused on patient care. It may include time spent supervising or mentoring trainees participating in direct patient care. Administration—Time devoted to program management, staff supervision, or managerial functions. Administration also may include time working on department and hospital committees or serving on state or national committees, advisory boards, or professional societies. Education—Time devoted to formal didactic education and teaching at a university. It may include managing a training program, but does not include time spent receiving continuing education or training or supervision or mentoring of students. Research—Time devoted to performing formal, approved health care research, or in activities in direct support of approved research. Research can be laboratory, clinical, or health services research. Examples include working in a research lab, serving on hospital or university research committees, supervising research, writing for publications or grants, attending research meetings, presenting at meetings, and preparing presentations or publications. Time spent in clinical research that produces clinical workload may be allocated to direct patient care. Labor mapping assigns labor cost and hours to the work unit in which the work occurred. If a clinician works in more than one unit, labor time is allocated to each unit. If an SLP works 40 hours in Clinic A and 40 hours in Clinic B, that clinician's labor time would be distributed as 50% in each unit. If the employee were mapped 100% to Clinic A, even though he or she worked there only half of the time, Clinic A would appear to be less productive because of the additional labor that would be mapped to that unit without any direct patient care production. Conversely, the productivity of Clinic B would be overstated because the employee's labor was not mapped to that unit although the provider contributed patient care hours to that unit. Productivity Methods Productivity can be measured in many ways, such as counting the number of patients seen, the number of visits or encounters per clinician, or the number of billable hours, or by calculating the percentage of on-duty hours spent in direct patient care (Table 1 [PDF]). Three common productivity methods are based on workload, capacity, and relative value units (RVUs). Workload-Based Method Perhaps the simplest productivity statistics to compile are workload-based systems. They typically include the number of visits, procedures, encounters, or patients. They provide an easily understood indication of the volume of work. The major disadvantage of workload-based methods, however, is that they usually do not take into account the complexity of services—all services are counted equally. Capacity-Based Method Capacity measures also are easy to construct. They are based on typical appointment length and are usually adjusted for clinician availability (e.g., the model adjusts to scheduled hours in the clinic, vacation time, and projected no-shows or other planned down time). These models are usually prospective (i.e., they show how many encounters a clinician should generate). When compared with workload models, the capacity model can demonstrate how well clinicians meet productivity goals (e.g., number of patients seen). Like workload-based methods, capacity methods value each encounter equally, regardless of complexity. Capacity models also do not provide information on how efficiently services are provided. The capacity models shown in Table 2 [PDF] illustrate how adjustment of time allocated to each appointment slot will affect the expected productivity. The models were constructed with the following assumptions: 260 possible work days (52 weeks/year, five days/week) reduced by scheduled holidays, leave, mandatory continuing education, and related professional assignments, leaving 202 possible work days per year. Assuming a typical work day of eight hours, minus one hour for lunch and breaks, there are seven hours of direct patient care per day or 1,414 DPC hours per year. The key element that determines productivity is the duration of the appointment slot. In Model C, for example, the typical appointment takes 45 minutes; a full-time employee should generate 1,885 patient visits per year. Patient no-shows—scheduled time that does not generate direct patient care time (wasted capacity)—also must be factored in the capacity model. This model, also called panel size, indicates the number of patients for which an audiologist or SLP is responsible, given scheduled availability. This model can be particularly useful in projecting how many clinicians a facility will need to hire for an expected demand. The danger in using this kind of model is the temptation to increase capacity by reducing appointment length. This scenario creates an ethical dilemma by reducing patient care time and possibly affecting the quality of patient care. It may be unsustainable because other factors—such as time needed to complete documentation, analyze results, coordinate care, attend team meetings, process orders, or teach students—are not included in the model. Driving capacity upward by reducing the time allocated to each patient may have undesirable consequences such as poor quality, errors, low morale, and low patient satisfaction. In this model, it is better to overestimate the appointment time to account for time that is not face-to-face direct patient care but is nevertheless essential to delivering quality patient care. RVU–Based Method Workload- or capacity-based models count each episode of care equally—that is, they do not account for the complexity of services. The relative value unit (RVU) productivity method has the advantage of weighting procedures by their complexity. There are three methods for establishing an RVU: Time Studies. A clinic can conduct a time study to determine how much time each procedure takes. This time becomes the RVU. An alternative method is to appoint an expert panel to arrive at a consensus on procedure times, a method that reflects actual local practice. Conversely, these RVUs cannot be standardized across health care facilities. Resource-Based Relative Scale. Another option is the Resource-Based Relative Value System (RBRVS) of the Centers for Medicare and Medicaid Services, which receives substantial input from the American Medical Association (AMA). RVUs in this methodology are dimensionless. As the name implies, they are based on a relative value scale that weights all CPT procedure codes. The AMA, with input from specialty societies, assigns a relative value to each CPT code. The RVU has three components: professional work (time, technical skill, physical effort, stress, and professional judgment); practice expense (overhead costs and non-physician labor); and professional liability (malpractice costs). RVUs are available in the Physician Fee Schedule published by the Centers for Medicare and Medicare Services (CMS). These RVUs have two major advantages: They account for complexity on a relative scale and they can be benchmarked to the productivity of other facilities. The major disadvantage of using RVUs as a productivity measure is that not all audiology and speech-language pathology services are captured by CPT codes or covered by Medicare. This method also may not capture professional time involved for case histories, decision making, floor time, counseling, coordination of care, documentation, data analysis, or chart review (evaluation and management services). Labor Time. Fortunately, the RVUs include time-based clinical labor components. CMS maintains a file of direct labor times for each procedure. These time values can be applied to time-based productivity calculations. Table 3 [PDF] shows examples of direct labor values for two audiology procedures (92553 and 92633) and two speech-language pathology codes (92506 and 92507) extracted from the CMS practice expense labor file. Some audiology and speech-language pathology procedures have professional work values. This component also contains a direct labor time value. Table A [PDF] shows examples of procedures from the physician labor file. Some audiology and speech-language pathology services have both professional work and practice expense (technical) components. Table B [PDF] shows examples of procedures that have both professional (modifier 26) components and technical (modifier TC) components. If the clinician administers and interprets the test, the combined value (known as the global) is the RVU time. Using RVU-Based Productivity Simply defined, time-based productivity is the ratio of labor output (time needed to generate clinical procedures) to labor input (worked hours). For example, a clinical procedure takes 10 minutes to perform (the RVU). The clinician generates 1,000 of these procedures (the clinical volume). Therefore, it takes 10,000 minutes (or 166.66 hours)—the labor output—to perform these procedures. This labor output (also called specified hours) becomes the numerator of the productivity ratio. Computing productivity requires knowing how much time the clinician worked. Payroll shows 180 worked hours. This time becomes the denominator of the productivity ratio. The productivity is calculated as: 166.66/180 = 92.58%. That is, 92.58% (154.3 hours) of the clinician's possible on-duty hours were spent in direct patient care. Conversely, 7.42% (13.34 hours) were not specified (i.e., not associated with production). This level is a very strong degree of individual productivity. It has been long established in social science research that productivity ratios at or above 75%–78% are good levels of productivity. Table 4 [PDF], which shows application to the clinic level, depicts a productivity report for a clinic with 7.8 employees. The report shows work as hours and full-time employee equivalents (FTEs). FTE is calculated by dividing the total hours by the number of possible work hours in a year: 2,080 hours (52 weeks at 40 hours per week). There were 16,224 total paid hours (7.8 FTE x 2080 hours). Clinicians used 2,438 hours of vacation, sick leave, and holiday time, or 1.17 FTE, resulting in 13,786 possible on-duty work hours or 6.66 FTE. The clinic generated 11,063 direct patient care hours or 5.32 FTE. Direct patient care (specified) hours are the accumulated RVUs associated with procedures multiplied by the clinical volume of the procedures performed. The productivity ratio is calculated by dividing the total direct patient care hours by the worked hours. In this example, the productivity (specified percent worked) was 80.24%. Managers need to pay particular attention to unspecified hours (difference between the possible worked hours and direct patient care hours). In this example, there were 2,723 unspecified hours (1.31 FTE). Unspecified hours do not necessarily mean non-productive hours, and may include direct patient care activities such as analyzing data, making decisions, planning and coordinating care, documentation, ordering and handling devices, and inter-disciplinary team meetings that are not associated with specific procedure codes. Comparing Productivity Methods Workload-based statistics (e.g., number of visits, encounters, or caseload) give information about the volume of work, but not how efficiently the work is being delivered. For example, Clinic A produced 10,000 visits and Clinic B produced 5,000 visits. Based on workload-based statistics, Clinic A is more productive than Clinic B. If both clinics have the same staff size (3.0 FTE), Clinic A generated 3,333 visits per FTE and Clinic B generated 1,667 visits per FTE. Using a per-FTE workload-based metric, we would again say that Clinic A is more productive because it generates more visits. Looking at the complexity of the procedure performed by the two clinics reveals a different picture. Clinic A generated 10,000 procedures with RVU=10 minutes. Clinic B produced 5,000 procedures with RVU=60 minutes. Under an RVU-based analysis, Clinic A generated 100,000 RVU minutes (1,667 RVU hours) and Clinic B produced 300,000 RVU minutes (5,000 RVU hours). Both clinics had 5,520 possible work hours (3.0 FTE x 1,840 on-duty work hours). Clinic A has a productivity of 30.2% and Clinic B has a productivity of 90.6%. A clinic can look very productive in terms of visits but actually be quite inefficient when the complexity of procedures is considered. A Bigger Picture RVU-based productivity models provide a simple and informative alternative to traditional workload-based or capacity-based methods. These RVU methods are powerful and flexible. For example, Medicare RVU data provide a standardized way to weight procedures by complexity and can be used to calculate billable productivity (percent of on-duty hours that generate billable hours). Time-based productivity methods allow easy calculations of the percentage of on-duty hours associated with direct patient care. Finally, these models can be used to create models to predict how much staff will be needed to meet expected demand. Simply measuring productivity, however, is not an effective solution to cost management. Clinicians in hospital settings also need to consider other factors including long-term sustainability, staff morale, outcomes, quality, and constraints that limit patient flow through the clinic. The opinions expressed herein are those of the authors and do not necessarily reflect the opinions or official positions of the Department of Veterans Affairs or the U.S. Government. References American Speech-Language-Hearing Association (2009). ASHA SLP Health Care Survey Report: Workforce and Work Conditions Trends, 2005–2009. Google Scholar American Speech-Language-Hearing Association (2009). ASHA SLP Health Care Survey 2009: Workforce and Work Conditions. Google Scholar American Speech-Language-Hearing Association (2009). Productivity. Available from www.asha.org/slp/productivity.htm. (Members only). Google Scholar Centers for Medicare and Medicare Services. Physician Fee Schedule. www.cms.gov/PhysicianFeeSched/PFSFRN/itemdetail.asp?filterType=none&filterByDID=99&sortByDID=4&sortOrder=descending&itemID=CMS1223902&intNumPerPage=10 Google Scholar Author Notes is an audiologist at the National Audiology and Speech Pathology National Program Office for the Department of Veterans Affairs. Contact him at [email protected]. is chief of the Audiology and Speech Pathology Service at the VA New York Harbor Health Care System. Contact him at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetailsCited ByPerspectives of the ASHA Special Interest Groups7:4 (1120-1136)15 Aug 2022Impact of Clinical Education of Student Clinicians on Speech-Language Pathologists' Productivity in Medical SettingsJennifer St. Clair, Karen J. Mainess, Paige Shaughnessy and Benjamin BecerraAmerican Journal of Audiology28:3 (628-659)13 Sep 2019Pediatric Audiology Productivity: Results From a Multicenter SurveyWendy Steuerwald, Lisa L. Hunter and Roanne Karzon Volume 16Issue 6June 2011 Get Permissions Add to your Mendeley library History Published in print: Jun 1, 2011 Metrics Downloaded 2,841 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2011 American Speech-Language-Hearing AssociationLoading ...

The impact of a Critical Care Information System (CCIS) on time spent charting and in direct patient care by staff in the ICU: A review of the literature

The aim of this study was to determine how much time nurses spend on direct and indirect patient care in acute and subacute hospital settings. Quantifying direct and indirect nursing care provided during inpatient stay is vital to optimise the quality of care and manage resources. Time and motion cross-sectional observational study and reported the study according to the STROBE guideline. Nurses working in an acute or subacute medical wards of a single health service participated. Nurses were observed twice for 2 h on the same day with an observer break in between sessions. Real-time task-related data were digitally recorded using the Work Observation Method By Activity Timing (WOMBAT) tool by a single research assistant. Frequency and time spent on pre-determined tasks were recorded and included direct care, indirect care, documentation, medication-related tasks, communication (professional) and other tasks. Task interruptions and multitasking were also recorded. Twenty-one nurses (acute n = 12, subacute n = 9) were observed during shifts between 7 AM and 9 PM in May-July 2021. A total of 7240 tasks were recorded. Nurses spent a third of their time on direct patient care (27% direct care and 3% medication administration). A total of 556 task interruptions occurred, mostly during documentation, and medication-related tasks. A further 1385 tasks were performed in parallel with other tasks, that is multitasking. Time spent on tasks was similar regardless of the setting and was consistent with previous research. We found differences in the distribution of tasks throughout the day between settings, which could have implications for workforce planning and needs to be investigated further. Interruptions occurred during documentation, direct care and medication-related tasks. Local-level strategies should be in place and regularly revised to reduce interruptions and prevent errors. Relevance to clinical practice The association between interruption and increased risk of error is well-established and should be an ongoing area of attention including observations and education provided in local settings.

Extracorporeal Membrane Oxygenation: Opportunities for Expanding Nurses' Roles.

American society for parenteral and enteral nutrition (a.s.p.e.N.) standards of practice for nutrition support pharmacists.

Workload in ICU nurses: A systematic review and meta-analysis of the Nursing Activities Score.

Families are reporting loss of interactions and communication in response to restrict isolation measures. Other tangible losses include income, access to resources, engagement, involvement in decision-making process and other planned activities. Listening to families' needs, concerns and say has been identified as one of the most important and least accomplished health care providers' roles in the intensive care units (ICUs). (1) To explore the experiences and concerns of Arab family members and health care professionals facing the challenges during ICU isolation, and (2) to develop recommendations for enhancing family support and improving effective communication to better address the needs of families during ICU isolation. This study utilizes a qualitative descriptive phenomenological design. We analysed data gained from 32 family members' concerns during their ICU patients' stay in isolated room settings and 21 health care providers' reflections through 2 focused groups recruited from Emirati and Egyptian ICUs. Thematic analysis revealed two main themes. The first theme, Family Members' Perspectives, highlights families' emotional and logistical challenges, including fears about infection, frustration over delayed updates and barriers to advocating for their loved ones. Subthemes include (a) family experiences and emotional challenges and (b) family-derived recommendations, such as implementing regular video calls, providing detailed patient updates and allowing occasional controlled visits to the ICU. The second theme, Health Care Providers' Perspectives, reflects HCPs' professional challenges in balancing family engagement with clinical demands. Subthemes include (a) challenges faced by HCPs, such as time constraints and communication difficulties, and (b) HCP-derived suggestions, including the integration of liaison nurses, social workers and revised visitation policies to enhance family-centred care. Families expressed concerns regarding the post-ICU discharge plan, prognosis and treatment quality. They proposed regular calls and video conferences as key methods for expressing preferences, emphasizing the importance of their active involvement during isolation. In response, health care providers acknowledged the imbalance in family-centred care and recommended expanding the ICU team to include social workers, psychologists and liaison nurses to better address the holistic needs of patients and families in isolation. This study underscores the critical role of family support and involvement in ICU care, specifically highlighting the responsibilities of ICU nurses. It calls for targeted policy modifications, the implementation of structured communication strategies and the establishment of a supportive environment to enhance family engagement. By equipping ICU nurses with the necessary resources, training and tools, these strategies aim to optimize family-centred care, improve the quality of communication and ultimately contribute to better patient outcomes in intensive care settings.

Intensive care units (ICU) patients are highly vulnerable to inaccurate drug dosing. Pharmacogenomics (PGx) studies the role of inherited genetic variation in drug metabolism and dose efficacy. To assess the prevalence of PGx variants that may influence therapeutic effect in the ICU, we carried out whole genome sequencing (WGS) of 210 Qataris in ICU care at Hamad Medical Corporation (HMC), Doha, Qatar and assessed the WGS for predicted deleterious variants of genes that metabolize 30 drugs commonly prescribed in the ICU. PGx variation was evaluated using two complementary approaches. First, variants with established functional interpretation were assessed using CPIC guidelines and star-allele haplotypes inferred by PharmCAT to estimate the prevalence of alleles associated with abnormal drug metabolism. Second, a broader exploratory analysis examined computationally predicted deleterious single-nucleotide variants in pharmacogenes that currently lack CPIC guidelines or defined star alleles, with these findings interpreted as descriptive of genomic variation rather than clinical metabolizer phenotypes.Of the ICU patients that received the 5 most commonly prescribed drugs (warfarin, phenytoin, midazolam, vancomycin, levetiracetam), 93% had deleterious metabolism-related variants. Ninety-one % of ICU patients carried at least one variant in a gene with known PGx relevance that could potentially impact the metabolism or activity of at least one medication they received. Most patients had ≥14 deleterious variants of genes that affect the metabolism of administered drugs. Comparison of the deleterious variants related to metabolism of ICU drugs with African/African American and European populations revealed significant population specificity in ICU related PGx variants. Together, these data suggest that population specific, PGx based on the individual’s genome likely plays a significant role in effective, safe dosing in the ICU setting.

A tool to assist in optimal allocation of available nursing resources is of paramount importance. The goals of this study were as follows: (1) to determine whether the standard time values of the Belgian Nursing Minimum Dataset are a valid basis for the development of a Workload Indicator for Nursing; (2) to quantify the impact of factors that most influence nursing workload; and (3) to examine the cross-impact of items of the Belgian Nursing Minimum Dataset. This research project is a prospective observational study with exploratory aspects. The data for this prospective study were collected during September 2010 from a convenience sample of 23 nursing units in four hospitals in Belgium. The data collection included three parts: (1) the registration of the items of the Belgian Nursing Minimum Dataset; (2) the amount of time committed to direct patient care; and (3) analysis of variables, which influence the nursing workload at patient and unit level. The correlation coefficients for the sum of Direct and Indirect Patient Care and the Workload Indicator for Nursing-score of the surgical, internal medicine and intensive care units were 0·85, 0·88 and 0·89 respectively. Significant differences in standard time utilization for nursing activities at the patient level are directly related to the level of mobility assistance required. Units needing significantly more time for Direct and Indirect Patient Care than predicted by the Workload Indicator for Nursing-score had a higher mean number of complex nursing activities per patient. The high correlation coefficients between the total time utilized for direct patient care and the WiN-score indicate that the standard time values of the Belgian Nursing Minimum Dataset are valid.

The aim of this investigation was to establish the distribution and proportion of nursing activity represented by patient-related care activities (direct and indirect), and other nursing activities (unit-related and personal) within one inpatient neurological rehabilitation unit. A set of tools has been developed for estimating the care/nursing hours required for direct hands-on patient care in hospital rehabilitation settings. However, to apply this information to estimate the actual staffing requirements in relation to a given caseload, it is necessary to know the proportion of nursing workload assigned to other activities and how this may vary throughout the day. A work sampling study was conducted during 2004. A snapshot of nursing activity was recorded at 5-minute intervals from 0600 to 2355 spread over 2 weeks, with one session from 0600 to 1525 and the second from 1530 to 2355. A total of 8883 nursing activities were observed and recorded over 126 hours and categorized as follows: 4060 (46%) direct patient care, 2218 (25%) indirect patient care, 874 (10%) unit-related and 1731 (19%) personal time. The proportions of direct care fluctuated throughout the day, with direct care activities mainly concentrated in early mornings and to a lesser extent evenings. Direct patient care accounted for less than half of the nursing activity in a rehabilitation setting. Estimates of staffing requirement must also take account of the time required for indirect care and non-patient related activity.

Critical care is an expensive and limited resource in the United States. Estimates from more than a decade ago suggest that over $100 billion a year is spent on critical care services.1 Over the past two decades, the number of patients presenting to the Emergency Department (ED) requiring critical care services has increased at a much higher rate than the growth in overall ED volume.2,3 The proportion of ED patients requiring Intensive Care Unit (ICU) admission has increased 75% over the first decade of the twenty-first century. In addition to the increase in the absolute number of patients requiring critical care admission, the ED length of stay for critically ill patients increased by 60 minutes. This resulted in a total nationwide increase in critical care provided in the ED by more than threefold. This disproportionate increase in critical care time reflects both the increase in critical care volume and the increase in ED boarding of critically ill patients. Data from 2008 reported the median boarding time for a patient waiting in the ED for an ICU bed was more than 5 hours, and 30% of patients waited more than 6 hours for an ICU bed.2,3 This article is protected by copyright. All rights reserved.