A few years ago at a conference, I learned about a hospital initiative that allowed family members to be present 24/7 with their loved ones, often in the most challenging of environments, such as the intensive care unit.
I was hesitant to accept this practice.
An ICU room is filled with lifesaving equipment — ventilators hissing, monitors beeping, red and green lights flashing — around which doctors and nurses carefully maneuver. If families are there, the nurses must keep a watchful eye to make sure that no equipment is moved. “Nurses like to be in control of their work environment,” an ICU nurse manager told me.
Moreover, in the ICU, a family member could become distressed at seeing their loved ones bucking the ventilator or bleeding from a fresh wound.
However, my reluctance counters the change that is occurring in our health care system: a movement toward more “patient-centered care,” in which patients and families are involved in shared decision-making.
Patient-centeredness is one of the six goals of the Institute of Medicine in redesigning the American health-care system, along with safety, effectiveness, efficiency, equity and timeliness. And under a new payment scheme, launching in 2013, hospital payments will be based in part on surveys that ask patients and families how well the doctors and nurses communicated and whether they were responsive to patient needs.
Over the past few years, the ICU at one of my hospitals has been field-testing a more open approach. We are not the first to do so. Geisinger Medical Center in Danville, Pa., went to an open ICU policy nearly a decade ago, found it extremely disruptive and soon reverted to only 30 minutes of visiting six times a day. On a second attempt, however, Geisinger developed an extensive communication program for both families and staff, and open ICU visitation has been successful since 2003. A 1997 study found that open ICU visitation practices had a beneficial effect on 67 percent of patients and 88 percent of families.
I am surprised by how well the open policy at our hospital has worked over the past months. I have become comfortable seeing family members stretched on recliners in the ICU during my early-morning visits. They update me on how the night went for the patient. One ICU specialist said, “I don’t have to chase down families to update them on what is happening.”
Some ICUs are also inviting families to participate when a team of a dozen professionals, including doctors, nurses, pharmacists and social workers, decide on the day’s plan for the patient.
“I’m not sure that is such a good idea,” one cardiologist told me. It was 8:30 in the evening, and he still had not finished seeing his patients.
I understand his reluctance. During rounds, doctors and nurses exchange medical jargon and spew numbers like auctioneers. Would family members understand what it means when we say their loved one “needs a cabbage” (a coronary artery bypass graft, or CABG)? Would the team hesitate to talk about potential causes of an illness, such as HIV or cancer, or to refer to “an extremely poor prognosis”?
And what if patients and relatives want to photograph or video a doctor visit? One patient in seven experiences an adverse event during a hospital stay. Inviting families to be with their loved ones during rounds will mean that lawyers will have a field day, one internist told me.
Steve Bergeson, medical director for quality at Allina Health Systems in Minnesota, told me that doctors and nurses are afraid that “families will find out that something went wrong and will be upset.”
I asked the ICU nurse manager at my hospital what nurses do when the family is in an ICU room and something goes terribly wrong, like a patient requiring CPR. “We ask the family to step out,” she explained, “and if they want to be present in the room, one of the nurses stands to the side with them and explains what is happening.”
In pediatrics and childbirth, we are far ahead in patient-centered care. No one hesitated when I said I wanted to be with my wife for the delivery of our children, even when things went bad and the obstetrician had to pull my daughter out with forceps to find the umbilical cord wrapped around her neck six times.
The more I think about it, the more I realize that movement toward greater transparency is a journey that each health system, its medical staff and its patients have to make at their own pace. It cannot be mandated by a federal agency.
Also, health care is not like a business that can be governed by the simple adage that the customer is always right. But those of us who work in that system should think of every patient as an individual and respect his or her needs and wishes — a goal I heard most forcefully expressed at a conference about a decade ago about patient-centeredness.
“Nothing about me, without me.”
Source: Commercial Appeal