Co-led by UNC School of Medicine’s David Y. Hwang, MD, newly released updated guidelines from the Society of Critical Care Medicine (SCCM) reveal how family centered care for adult ICUs is paramount and an invaluable approach.
Imagine one of your family members being incredibly ill and admitted into the ICU. A range of emotions creep up like fear, anxiety, uncertainty and a desperate desire to see that family member recover. This impact on loved ones attempting to assist to the needs of the critically ill patient can often result in despair and hopelessness.
Building resilience during this physical and emotional hospital stay often involves a multi-centered approach to the planning, delivery, and evaluation of health care that is beneficial among patients, families, and health care professionals. To continue the efforts in making sure patients are receiving the highest quality care, an official set of newly updated international guidelines from the Society of Critical Care Medicine (SCCM) has now been released regarding best practices and clear recommendations for support of family members for adult ICU patients.
“Our hope is that as critical care evolves post-COVID that family-centered care will be central to the care of patients more than ever before,” said David Y. Hwang, MD, FAAN, FCCM, FNCS, professor of neurology, division chief of neurocritical care at the UNC School of Medicine, and corresponding author of the paper. “Between the recommendations themselves and an accompanying implementation toolkit, the guidelines package provides a practical roadmap for adult units that are looking to identify areas of improvement and implement positive changes for their patients’ families.”
Co-led by Hwang and Dr. Mona Hopkins of Brigham Young University, the guidelines published in Critical Care Medicine is the third iteration for family-centered care in adult ICUs; the last iteration was in 2017. The guidelines consist of four content sections: engagement of families, support of family needs, communication support, and support of ICU clinicians providing family-centered care. A multi-professional panel was established to publish these evidence-based recommendations. This panel issued 17 statements related to optimal family-centered care in adult ICUs, including one strong recommendation, 14 conditional recommendations, and two best-practice statements.
Following the 2017 guidelines, the 2020 COVID pandemic ignited negative effects on ICU family presence. The new guidelines issue a strong recommendation for ICUs to liberalize or to allow less restrictive hours of ICU family presence policies post-COVID. As COVID spread around the world, family presence in inpatient settings temporarily came to a halt. With the pandemic behind us, the recommendations make the case that defaulting family presence options to become more flexible by improving family visiting hours can promote equity and clinician-family trust in decision making. One meta-analysis performed for the guidelines found that liberalized policies demonstrated increased family satisfaction, possible increase in patient satisfaction, and reduced family and patient symptoms of anxiety and depression.
“There’s been a movement in ICUs in general for all families to be at the bedside with their loved ones,” said Hwang. “During COVID when there was a lot of visitor restrictions, the culture kind of shifted a bit. Following the pandemic, our writing team’s hope is that the default practice should shift back to being as inclusive as possible when it comes to visiting hours, as long as leadership believes that safety is being respected.”
The guidelines included conditional recommendations for family participation in bedside care. This approach involves having family members participate in hands-on care for their loved ones in manners that medical teams feel to be safe. As an example: if a loved one needs routine oral care in the ICU, a family member who is willing could be trained to help with this activity at the bedside, instead of on the sidelines.
“Some ICUs that are on the leading edge of this have a menu of things that they are comfortable in letting families do when they’re visiting their loved ones in ICU,” said Hwang. “If family members feel as though it would be therapeutic to be involved in bedside care, then they can be trained in things on the menu and have those opportunities. The hope is that this recommendation can help with the family’s mental health, too.”
The potential of losing a loved one can bring on a surge of emotions and stress. Attending to family mental health and psychological needs was also listed in the conditional recommendations. The panel in particular suggested providing spiritual and bereavement support to families of patients who have died in the ICU. Additional interventions for supporting families involved brochures or booklets; condolence letters; and meetings with specific care teams, such as palliative care, psychologists, or specially trained nurses. In meta-analyses performed for the guidelines, evidence pointed towards a connection between supporting ICU family mental health and improved family satisfaction and reduction of patient PTSD.
Burnout, fatigue, anxiety, and moral distress can all describe the state of a clinician’s well-being, especially those providing critical care services. The beginning of the COVID-19 pandemic fueled the flames of this burnout epidemic at an alarming rate. These new guidelines included another conditional recommendation in addressing the support of clinical teams in their efforts to provide family-centered care. To meet this need, recommendations suggest structured programs to support clinicians in promoting the delivery of family-centered ICU care. By supporting the clinician’s resilience and mental health, these efforts can create a domino effect in compassionate and empathetic care to patients’ families. The guidelines reveal that identifying and reducing these barriers could promote a positive impact in the healthcare setting.
A best practice statement was also issued that ICUs implement practices to identify and reduce barriers to help promote equitable critical care delivery for patients’ families. Some of these practices include offering families the option of being present on ICU rounds, offering family presence during resuscitation, providing family educational programs, providing ICU diaries, and providing communication skills training to clinicians. Another best practice statement recommended ICUs to implement supportive features to meet family needs during the patient’s hospital stay like rest spaces, areas of personal care, and spaces to interact with staff.
Decreasing family anxiety and depression and improving family satisfaction is at the heart of providing family-centered care. Maintaining quality care and physician wellness is also key for optimal hospital morale. The guidelines conclude that further research needs to be implemented to understand effective protocols for supporting and engaging families remotely and continuing to identify interventions that positively affect families, patients and clinician outcomes. Hwang acknowledges that these are important next steps in supporting family members of ICU patients.
Written by: Brittany Phillips, communications specialist, UNC Health | UNC School of Medicine