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ICU VISITATIONICU VISITATION……THE EVIDENCE IS OUT THERETHE EVIDENCE IS OUT THERE
Theresa Tomlinson RN, BSN
York Hospital
Open Heart Intensive Care Unit
Presentation ObjectivesPresentation ObjectivesPresentation ObjectivesPresentation ObjectivesPresentation ObjectivesPresentation ObjectivesPresentation ObjectivesPresentation Objectives
1. Define the practice issue regarding ICU visitation
2. State the EBP question
3. Describe the EBP process used by the ICU workgroup
4. List three EBP recommendations for implementing open
visitation in the ICU
The Johns Hopkins Nursing EvidenceThe Johns Hopkins Nursing EvidenceThe Johns Hopkins Nursing EvidenceThe Johns Hopkins Nursing Evidence----Based Practice Based Practice Based Practice Based Practice
Model and GuidelinesModel and GuidelinesModel and GuidelinesModel and Guidelines
The Johns Hopkins Nursing EvidenceThe Johns Hopkins Nursing EvidenceThe Johns Hopkins Nursing EvidenceThe Johns Hopkins Nursing Evidence----Based Practice Based Practice Based Practice Based Practice
Model and GuidelinesModel and GuidelinesModel and GuidelinesModel and GuidelinesThe PICOThe PICOThe PICOThe PICOThe PICOThe PICOThe PICOThe PICO QUESTIONQUESTIONQUESTIONQUESTIONQUESTIONQUESTIONQUESTIONQUESTION
Patient, Population, Problem
Intervention
Comparison with another variable
Outcome
PP
II
CC
O
The Patient, Population and ProblemThe Patient, Population and ProblemThe Patient, Population and ProblemThe Patient, Population and ProblemThe Patient, Population and ProblemThe Patient, Population and ProblemThe Patient, Population and ProblemThe Patient, Population and Problem
PPPPatient Adult ICU patients at York Hospital
PPPPopulation Family, visitors, and ICU staff
PPPProblem Inconsistent implementation of
visiting hours among and within the
ICUs.
Background and Current PracticeBackground and Current PracticeBackground and Current PracticeBackground and Current PracticeBackground and Current PracticeBackground and Current PracticeBackground and Current PracticeBackground and Current Practice
Why do we do that?Why do we do that?Why do we do that?Why do we do that?Why do we do that?Why do we do that?Why do we do that?Why do we do that? The InterventionThe InterventionThe InterventionThe Intervention
More structure to the visitation policy
The ComparisonThe ComparisonThe ComparisonThe Comparison
Current visitation policy at York Hospital
The OutcomeThe OutcomeThe OutcomeThe Outcome
Promotes patient safety and patient, family
& staff satisfaction
Our Current PracticeOur Current PracticeOur Current PracticeOur Current PracticeOur Current PracticeOur Current PracticeOur Current PracticeOur Current Practice
OHICUOHICUOHICUOHICU
0800 rounds
11am - 8pm
15 minutes post-op
CCUCCUCCUCCU 11am - 8pm
MSICUMSICUMSICUMSICU liberal visitation
TSICUTSICUTSICUTSICU
10 am - 12 pm
2 pm – 4 pm
6 pm – 8 pm
MTCUMTCUMTCUMTCU liberal visitation
STCUSTCUSTCUSTCU 11 am – 8 pm
EBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP 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?
The ICU Visitation WorkgroupThe ICU Visitation WorkgroupThe ICU Visitation WorkgroupThe ICU Visitation WorkgroupThe ICU Visitation WorkgroupThe ICU Visitation WorkgroupThe ICU Visitation WorkgroupThe ICU Visitation Workgroup
All ICUs in York Hospital were represented.
OHICUOHICUOHICUOHICU MSICUMSICUMSICUMSICU CCUCCUCCUCCU TSICUTSICUTSICUTSICU MTCUMTCUMTCUMTCU STCUSTCUSTCUSTCU
Stephanie
Church
Doris
Lentz
Margie
Lane
Cheryl
Churilla
Renee
Pruner
Maria Smith
Becky
Senft
Allison
Taylor
Collecting the EvidenceCollecting the EvidenceCollecting the EvidenceCollecting the EvidenceCollecting the EvidenceCollecting the EvidenceCollecting the EvidenceCollecting the Evidence
DatabasesDatabasesDatabasesDatabases
Pub Med , CINAHL , Pub Med , CINAHL , Pub Med , CINAHL , Pub Med , CINAHL ,
Cochran , Google Scholar,Cochran , Google Scholar,Cochran , Google Scholar,Cochran , Google Scholar,
reference lists, professionalreference lists, professionalreference lists, professionalreference lists, professional
organizationsorganizationsorganizationsorganizations
Key WordsKey WordsKey WordsKey WordsICU visitation, critical care ICU visitation, critical care ICU visitation, critical care ICU visitation, critical care
visitation, effects of visitation on visitation, effects of visitation on visitation, effects of visitation on visitation, effects of visitation on
patients, family visitation, and ICUpatients, family visitation, and ICUpatients, family visitation, and ICUpatients, family visitation, and ICU
Search ParametersSearch ParametersSearch ParametersSearch Parameters English language, articles from English language, articles from English language, articles from English language, articles from
1995199519951995----2011201120112011
# Articles # Articles # Articles # Articles 41 articles reviewed41 articles reviewed41 articles reviewed41 articles reviewed
7 articles discarded7 articles discarded7 articles discarded7 articles discarded
Evidence LevelEvidence LevelEvidence LevelEvidence Level Number of ArticlesNumber of ArticlesNumber of ArticlesNumber of Articles
I: Experimental 0
II: Quasi-experimental 1
III: Non-experimental/Descriptive 9
IV: Opinion of nationally recognized experts based on
scientific evidence6
V: Opinion of nationally recognized experts based on
experiential evidence.18
Levels of EvidenceLevels of EvidenceLevels of EvidenceLevels of EvidenceLevels of EvidenceLevels of EvidenceLevels of EvidenceLevels of Evidence
**41 articles reviewed. 7 articles were “C” quality and not used for
recommendations.
Definition of Open VisitationDefinition of Open VisitationDefinition of Open VisitationDefinition of Open VisitationDefinition of Open VisitationDefinition of Open VisitationDefinition of Open VisitationDefinition of Open Visitation
� Variable
�24/7
�Closed during resuscitation or codes
�Closed during change of shift report
�Closed during rounds
EVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTS
PATIENT
�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)
�Patients prefer to have family
near for support (Cypress, 2010)
EVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTS
FAMILY
1. Close proximity to the patient
2. Honest communication
3. To be informed
4. Care and support from staff
(Molter, 1976), (Gavaghn & Carroll, 2002)
EVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTSEVIDENCE HIGHLIGHTS
NURSING
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)
Support for Open VisitationSupport for Open VisitationSupport for Open VisitationSupport for Open VisitationSupport for Open VisitationSupport for Open VisitationSupport for Open VisitationSupport for Open Visitation
1. Institute of Medicine
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
EBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP QUESTIONEBP 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?
Practice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice Recommendations
Evidence shows that open visitation in
ICUs is safe to the patient and preferred by families and patients over structured
visitation policies.
Practice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice Recommendations
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
Practice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice Recommendations
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
Practice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice Recommendations
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
Practice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice Recommendations
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.
Practice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice RecommendationsPractice Recommendations
5. Expect Challenges
� Open visitation is a culture change for most ICUs
� Nursing will resist
- Education and communication will facilitate
change
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