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Second time’s the charm for open-visiting effort
Proactive communications make the difference
Breaking with tradition is never easy, especially when it comes to such sensitive areas as the intensive care unit (ICU). But at Geisinger Medical Center in Danville, PA, a second attempt at instituting open visiting in the adult ICU is working so well that is has become official policy.
Geisinger tried open visiting a few years earlier, but with little success. "What happened was we basically said, We’re open.’ We did not create any guidelines; we didn’t look at processes. We didn’t plan," explains Lani Kishbaugh, CCRN, clinical nurse educator for adult intensive care. "We also didn’t understand how to communicate what we needed to do for the patients; failures came from family members who became disruptive — and from staff who didn’t know how to ask them to leave when necessary. There were big communication issues."
In addition, such a concept runs counter to the traditional restricted visiting hours in the ICU. "In the past, this has been done in large part for the convenience of the caregiver," Kishbaugh explains. "Physicians always found it difficult to get work done, nurses felt they had a lot to do with the patients. And with the critical nature of the patients in the ICU, there was a tendency to limit the amount of stimulation."
Today, however, there is increasing evidence that having family more involved can improve outcomes and give staff access to somebody who knows a great deal about the patient. "The trend is to include as opposed to excluding," observes Kishbaugh.
This latest effort by Geisinger grew out of a challenge issued by Don Berwick, MD, MPP, president and CEO for the Institute for Healthcare Improvement (IHI) in Boston.
"He issued a challenge to all hospitals involved in the critical care collaborative of the IMPACT project at IHI," Kishbaugh recalls. "To my knowledge, we were the only hospital to accept."
According to IHI, IMPACT is "a network of health care organizations that are ready to join the improvement movement at a new level of ambition, scale, persistence, and transparency. The IMPACT vision is to make dramatic change in a specific area and improvements in multiple levels of the organization for overall transformation."
Berwick’s challenge called for the hospital to conduct a two-month test of open visiting.
"Because we had had a failure, we met with a lot of resistance from staff," Kishbaugh notes. "However, since we were involved in a pilot project, and they understood we could actually test small changes, they were willing to try it." The staff were more comfortable that the test would be performed on a small basis within limits, as opposed to the free-for-all it was before, she adds.
Geisinger was better positioned for success because it already had in place a family satisfaction group. "We started with that group, because we felt it was part of the IMPACT project and would be most affected by open visiting," notes Jennifer Donavan, RN, CCRN, the staff nurse who had been working closely with the group.
"We had already been working with them in terms of improved communication," Donavan adds, noting that they only had a few days to prepare for the program. "We kind of went cold turkey," she says. "It was like, OK. On Aug. 13, , we’ll be starting.’"
Communication was a critical component of the program, with several important vehicles and strategies employed. One, ironically, was to set limitations, despite — or perhaps because of — the fact that there would be open visiting. "We created an information pamphlet that included what you could and couldn’t do," Donavan says.
"This eased family and staff satisfaction." They sat down with the previous introduction to the unit, asked other staff about nuisance problems, and changed the publication accordingly. "We came up with a list and posted it over the door to the unit. We also posted a letter in the waiting room, saying basically, This is a trial, please bear with us while we do this test,’" she explains.
Staff were an important audience in the communications program as well. "We started with staff in group meetings, telling them what was coming and asking them what they felt the key issues would be," Kishbaugh points out. Several concerns centered on safety; for example, the fact that there could not be an unlimited number of people at bedside. Other issues involved age minimums and health department regulations.
"Another thing we focused on was, who will represent the family?" she adds. "The group created the position of family spokesperson — someone who gets updates from the doctor all the time and who has the responsibility of communicating to the family when they are not there." Because of Health Insurance Portability and Accountability Act (HIPAA) requirements, this individual is given a password so he or she can receive basic information over the phone.
Another effective strategy involved the use of beepers. "Before, we had families camping out, which was a big dissatisfier for nurses," Kishbaugh adds.
"We went to beepers so we could offer them to families who were reluctant to leave, so they could be in constant contact." These beepers have a messaging function, so the screen actually can say things such as, "Not an emergency." Beepers are now being tested in the cardiac ICU with open-heart surgery patients, she notes.
A bulletin board for family members also helped communicate important messages. It includes pictures that explain what they will see when they go into the ICU. "One big issue when we started was sterile procedures," Donavan recalls. "We’d shut down half the unit with a privacy screen, and other family members couldn’t get in. So we put up pictures on the board and explained why they were not able to visit — that we needed to prevent infection, that there were privacy concerns, and so on."
Surveys conducted with family members and staff showed positive results, Kishbaugh says. "Because we had already been working on communicating with families, the responses were pretty positive before, and there was not much room for dramatic improvement," she notes. "But the numbers did improve slightly." As for staff, the attitudes at the beginning were negative.
"At the end of two or three months, they had trended up to more positive responses," Kishbaugh reports. "By the first of the year, it had became second nature. Last month, we voted to change our policy to open visiting with guidelines, and we’re trying to spread it to other areas."
Of all the positive changes achieved by the program, perhaps the most critical, she says, was the establishment of trust between families and staff. "You would expect families to be here all the time because they can be, but actually since we’ve created a degree of trust, they’re not. When we used to try to limit access, they came sooner and sooner to try to get in; now, they base their decisions more on their own needs and how the patient is doing. If you can trust that caregiver, this is a very positive improvement."
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