The PICO QUESTION. Presentation Objectives. Background and Current Practice ICU VISITATION THE THE EVIDENCE IS OUT THERE

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1 ICU VISITATION THE THE EVIDENCE IS OUT THERE Presentation Objectives 1. Define the practice issue regarding ICU visitation 2. State the EBP question 3. Describe the EBP process used by the ICU workgroup Theresa Tomlinson RN, BSN York Hospital Open Heart Intensive Care Unit 4. List three EBP recommendations for implementing open visitation in the ICU The Johns Hopkins Nursing Evidence-Based Practice Model and Guidelines The PICO QUESTION P Patient, Population, Problem I Intervention C Comparison with another variable O Outcome The Patient, Population and Problem Background and Current Practice Patient Adult ICU patients at York Hospital Population Family, visitors, and ICU staff Problem Inconsistent implementation of visiting hours among and within the ICUs.

2 Why do we do that? The Intervention More structure to the visitation policy The Comparison Current visitation policy at York Hospital The Outcome Promotes patient safety and patient, family & staff satisfaction Our Current Practice OHICU CCU MSICU TSICU 0800 rounds 11am - 8pm 15 minutes post-op 11am - 8pm liberal visitation 10 am - 12 pm 2 pm 4 pm 6 pm 8 pm EBP QUESTION Is a more structured visitation regimen in the ICU more conducive to patient safety and rest, and nurse, patient and family satisfaction than our current ICU visitation policy? MTCU STCU liberal visitation 11 am 8 pm The ICU Visitation Workgroup All ICUs in York Hospital were represented. Collecting the Evidence Pub Med, CINAHL, Cochran, Google Scholar, Databases reference lists, professional organizations OHICU Stephanie Church Becky Senft Allison Taylor MSICU Doris Lentz CCU Margie Lane TSICU Cheryl Churilla MTCU Renee Pruner STCU Maria Smith Key Words Search Parameters ICU visitation, critical care visitation, effects of visitation on patients, family visitation, and ICU English language, articles from # Articles 41 articles reviewed 7 articles discarded

3 Definition of Open Visitation Levels of Evidence Evidence Level Number of Articles I: Experimental 0 II: Quasi-experimental 1 III: Non-experimental/Descriptive 9 IV: Opinion of nationally recognized experts based on scientific evidence 6 V: Opinion of nationally recognized experts based on experiential evidence. 18 Variable 24/7 Closed during resuscitation or codes Closed during change of shift report **41 articles reviewed. 7 articles were C quality and not used for recommendations. Closed during rounds PATIENT FAMILY Patients prefer to be given the choice for visiting preferences (Carroll, 2009) Visiting does not cause detrimental physiological changes (HR, BP, rhythm, ICP, stress hormones) (Fumigalli, 2006) 1. Close proximity to the patient 2. Honest communication 3. To be informed 4. Care and support from staff (Molter, 1976), (Gavaghn & Carroll, 2002) Patients prefer to have family near for support (Cypress, 2010) Support for Open Visitation NURSING 1. Institute of Medicine 1. Visiting policies are enforced to varying degrees in ICUs 2. Resistance to open visitation - patient safety - interruptions/delays in patient care - space -HIPAA (Lee et al., 2007), (Livesay et al., 2005), (Kirchoff & Dahl, 2006) 2. Centers for Medicare and Medicaid 3. Institute for Patient and Family-Centered Care 4. The Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals 5. Institute for Healthcare Improvement 6. Relationship-Based Care Initiatives

4 EBP QUESTION Is structured visitation in the ICU setting more effective than York Hospital s current policy in promoting patient safety and rest, and nurse, patient, and family satisfaction? Evidence shows that open visitation in ICUs is safe to the patient and preferred by families and patients over structured visitation policies. 1. Planning It s more than revising a policy Implementation of open visitation is an ongoing process - changes will happen along the way The process is lengthy - Use a trial period 2. Communication Involve all stakeholders in implementation (patient & family, ICU staff, security, leadership, RRT, PT, physician, risk mgmt ) - Patient Advisory Councils - Nursing Committees - ICU CET - staff surveys Use bulletin boards, pamphlets, signage 3. Education Disseminate the information Educate at many levels within the organization Incorporate education into required learning for staff Use many forms of education: presentations, posters, pamphlets for patients - Patient Educator/Liason 4. Broad Policy Recommendations The patient should dictate visitation preferences Utilize a spokesperson to maintain HIPAA Create a written visitation policy Safety and security of patient and staff should never be compromised.

5 References 5. Expect Challenges Open visitation is a culture change for most ICUs Nursing will resist - Education and communication will facilitate change Berti, D., Ferdinande, P., & Moons, P. (2007). Beliefs and attitudes of intensive care nurses toward visits and open visiting policy. Intensive Care Medicine, 33, doi: /s x Berwick, D. M., & Kotagal, M. (2004). Restricted visiting hours in ICUs: Time to change. Journal of the American Medical Association, 292, doi: /jama Brilli, R. J. (2004). Restrictions on family presence in the ICU [Peer commentary on the journal article Restricted visiting hours in ICUs: Time to change by D. M. Berwick]. Journal of the American Medical Association, 292(22), doi: /jama b Carroll, D. L., & Gonzalez, C. E. (2009). Visiting preferences of cardiovascular patients. Progress in Cardiovascular Nursing, Cypress, B. S. (2010). The intensive care unit: Experiences of patients, families, and their nurses. Dimensions of Critical Care Nursing, 29, Damboise, C., & Cordin, S. (2003). Family-centered critical care: How one unit implemented a plan. American Journal of Nursing, 103, 56AA-56EE. Retrieved from Davidson, J. E., Powers, K., Hedayat, K., Tieszen, M., Kon, A. A., Shepard, E.,... Levy, M. (2007). Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American college of critical care medicine task-force Critical Care Medicine, 35, doi: /01.CCM EB Ellis, K. (1988). Asking visitors to leave: When and how to do it. Nursing88, 64. Eriksson, T., & Bergbom, I. (2007). Visits to intensive care unit patients-frequency, duration and impact on outcome. Nursing in Critical Care, 12, Farrell, M. E., Joseph, D. H., & Schwartz-Barcott, D. (2005). Visiting hours in the ICU: Finding the balance among patient, visitor and staff needs. Nursing Forum, 40, Fontaine, D. K., Briggs, L. P., & Pope-Smith, B. (2001). Designing humanistic critical care environments. Critical Care Nursing Quarterly, 24, Fumigalli, S., Boncinelli, L., Lo Nostro, A., Valoti, P., Baldereschi, G., Di Bari, M.,... Machionni, N. (2006). Reduced cardiocirculatory complications with unrestrictive visiting policy in an intensive care unit: Results from a pilot, randomized trial. Circulation, 113, Retrieved from Garrouste-Orgeas, M., Philippart, F., Timsit, J. F., Diaw, F., Willems, V., Tabah, A.,... Carlet, J. (2008). Perceptions of a 24- hour visiting policy in the intensive care unit. Critical Care Medicine, 36, doi: /01.CCM F8 References Gavaghan, S. R., & Carroll, D. L. (2002). Families of critically ill patients and the effect of nursing interventions. Dimensions of Critical Care Nursing, 21, Giannini, A. (2010). The open ICU: not just a question of time [Peer commentary on the journal article Restricting visiting in ICUs is neither caring, compassionate, nor necessary by D. M. Berwick & M. Kotagal]. Minerva Anestesiologica, 76(2), Hardin, S. R., Bernhardt-Tindal, K., Hart, A., & Henson, A. (2011). Ciritical-care visitation: The patients perspective. Dimensions of Critical Care Nursing, doi: /DCC.0b013e3181fd03a0 Heitman, L., & McClard, C. (2009). Innovative solutions-the art of improvisation: Patient and family preferences for visitation in critical care. Dimensions of Critical Care Nursing, 28, Henneman, E. A., & Cardin, S. (2002). Family-centered critical care: A practical approach to making it happen. Critical Care Nurse, 22, Retrieved from Hunter, J. D., Goddard, C., Rothwell, M., Ketharaju, S., & Cooper, H. (2010). A survey of intensive care unit visiting policies in the United Kingdom. Anaesthesia, 1-5. doi: /j x Institute for Patient-and Family-Centered Care. (2010). Changing hospital visiting policies and practices: supporting family presence and participation (Executive Summary). Bethesda, MD: Author. Kirchoff, K. T., & Dahl, N. (2006). American Association of Critical-Care Nurses national survey of facilities and units providing critical care. American Journal of Critical Care, 15, Retrieved from Kishbaugh, L. (2004). Second time s the charm for open-visiting effort. Healthcare Benchmarks and Quality Improvement, Kleinpell, R. M. (2008). Visiting hours in the intensive care unit: More evidence that open visitation is beneficial. Critical Care Medicine, 36, doi: /.01.CCM. Latour, J. M. (2007). Families in the ICU: Do we truly consider their needs, experiences and satisfaction?. Nursing in Critical Care, 12, Lee, M. D., Freidenberg, A. S., Mukpo, D. H., Conray, K., Palmisciano, A., & Levy, M. M. (2007). Visiting hours policies in New England intensive care units: Strategies for improvement. Critical Care Medicine, 35, doi: /.01.CCM AC Livesay, S., Mokracek, M., Sebastian, S., & Hickey, J. V. (2005). Nurses perceptions of open visiting hours in neuroscience intensive care unit. Journal of Nursing Care Quarterly, 20, Marco, L., Bermejillo, I., Garayalde, N., Sarrate, I., Margall, M. A., & Asiain, M. C. (2006). Intensive care nurses beliefs and attitudes towards the effect of open visiting on patients, family and nurses. Nursing in Critical Care, 11, References Obama, B. (2010). Hospital visitation (Presidential Memorandum). Retrieved from Petterson, M. (2005). Process helped gain acceptance for open visitation hours. Critical Care Nurse, 25, Retrieved from Plowright, C. (2007). Visiting practices in hospitals. Nursing in Critical Care, 12, doi: Retrieved from Ramsey, P., Cathelyn, J., Gugliotta, B., & Glenn, L. L. (2000). Restricted versus open ICUs. Nursing Management, Retrieved from Rogness, B., Henrickson, K., Kohout, M., Smith, A., Brennan, L., Greene, M. T.,... Popies, J. (2008). Flexible ICU visitation hours improve family involvement in care. Retrieved from Roland, P., Russell, J., Richards, K. C., & Sullivan, S. C. (2001). Visitation in critical care: Processes and outcomes of a performance improvement initiative. Journal of Nursing Care Quarterly, 15, Retrieved from Rollins, G. (2005). Open all hours. Retrieved from Scanlan, C. F. (2010, December 15). Final CMS rules on patient visitation rights (Memo). Retrieved from The Hospital & Healthsystem Association of Pennsylvania: Sims, J. M., & Miracle, V. A. (2006). A look at critical care visitation. Dimensions of Critical Care Nursing, 25, Retrieved from The Hospital & Healthsystem Association of Pennsylvania. (2010). Important provisions in the final rule (Fact Sheet). Retrieved from The Hospital & Healthsystem Association of Pennsylvania: To comply with new TJC standards, toss out restictive visitation policies. (2010). Patient Education Management, 17, Retrieved from Van Horn, E. R., & Katz, D. (2007). Promotion of family integrity in the acute care setting. Dimensions of Critical Care Nursing, 26, Vandijck, D. M., Labia, S. O., Geerinckx, C. E., Puydt, E. D., Bolders, A. C., Claes, B., & Blot, S. I. (2010). An evaluation of familycentered care services and organization of visiting policies in Belgian intensive care units: A multicenter survey. Heart & Lung, 39, doi: /j.hrtlng Whitcomb, J. A. (2010). Evidence-based practice in a military intensive care unit family visitation. Nursing Research, 59, S32- S39. Retrieved from White, S. K. & Edwards, R. J. (2006). Visitation guidelines promote safe, satisfying environments. Nursing Management, Retrieved from Thank You