Implementing Intensive Care Unit Family-Centered Care: Resources to Identify and Address Gaps.

AACN Advanced Critical Care Volume 28, Number 2, pp. 148-154 © 2017 AACN

Implementing Intensive Care Unit Family-Centered Care: Resources to Identify and Address Gaps David Y. Hwang, MD Robert El-Kareh, MD, MPH Judy E. Davidson, RN, DNP

ABSTRACT During creation of the 2017 Society of Critical Care Medicine Guidelines for FamilyCentered Care in the Intensive Care Unit, 2 implementation tools were developed to assist intensive care unit clinicians in incorporating the new recommendations into local practice: a gap analysis tool and a work tools document. The gap analysis tool helps intensive care unit teams rapidly develop unit- or organization-specific recommendations to enhance family-centered care and assess local barriers to implementation. The

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roviding family-centered care (FCC) is a core goal of critical care providers and a responsibility of all intensive care unit (ICU) clinicians and leaders.1 The Society of Critical Care Medicine (SCCM) guidelines1 for FCC were updated in 2017 to include 24 best practice recommendations.2 When adopting new practice guidelines, clinicians should assess current practices and create an action plan for evidence-based improvements. This structured approach to updating practices can make an otherwise daunting task more manageable. In this article, we provides clinicians with strategies to assess local practices and develop institution- or unit-specific plans to optimize FCC according to the updated SCCM recommendations. During creation of the updated FCC guidelines, the writing team understood that developing tools to help individual ICUs with implementing the guidelines was important. Implementation tools would

work tools document identifies readily available and tested resources that may further assist with action planning for change. The goal of these implementation tools is to promote rapid translation of the SCCM Guideline recommendations into practice, thereby streamlining the process of enacting meaningful evidence-based practice change. Keywords: family, family-centered care, intensive care, neonatal, critical care, nursing

enhance the FCC guidelines’ practicality and increase the likelihood that their use would have a real impact on clinical care. To this end, assessment instruments that were developed to appraise the quality of practice David Y. Hwang is Assistant Professor of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT 06520 ([email protected]). Robert El-Kareh is Associate Professor of Medicine, Divisions of Biomedical Informatics and Hospital Medicine, University of California, San Diego Health, La Jolla, California. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California, San Diego Health, San Diego, California. Dr Hwang has received research grant support from the Neurocritical Care Society and speaker’s honoraria from SCCM. He also is participating in the National Institutes of Health Loan Repayment Program. For the remaining authors, no conflicts of interest were declared. DOI: https://doi.org/10.4037/aacnacc2017636

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Figure 1: Partial screenshot of the ﬁrst worksheet in the gap analysis tool. The drop-down menu is used to indicate how frequently each recommendation is currently implemented in the user’s ICU. In this sample, although recommendation 2 is worth 3 outcome points and recommendation 3 is worth 5 outcome points, recommendation 2 has a higher outcome score (and therefore a higher item rank) because the user indicated that his or her ICU currently implements recommendation 2 “nearly never,” whereas recommendation 3 is implemented “sometimes.” Abbreviation: ICU, intensive care unit.

guidelines specify that authoring organizations must provide tools that outline how recommendations can be translated into practice.3 The FCC guidelines writing team partnered with the SCCM Patient and Family Support Committee to create 2 tools: (1) a gap analysis tool and (2) a work tools document. The gap analysis tool helps teams of local ICU clinicians rapidly assess which recommendations are most needed for practice change as well as understand local barriers to implementation. The work tools document identifies available tested and recommended resources that may help clinicians plan for local change. The goal of both implementation tools is to streamline the process of enacting meaningful FCC change. Gap Analysis Tool A gap analysis tool is a standard performance improvement strategy used to evaluate existing practice against best practice. The gaps between existing practice and best practice are then analyzed and used to create a priority list for change. Gap analysis tools have been developed by the Agency for Healthcare Research and Quality (AHRQ) and other national groups promoting quality improvement in health care.4 Gap Analysis Tool Description

A task force of the SCCM Patient and Family Support Committee developed a gap analysis tool to help ICU clinicians quickly rank each of the 24 new FCC

recommendations with respect to the need for improvement in local practice environments and to assess how local barriers might affect the priorities for development of FCC improvement projects. The gap analysis tool was designed to be intuitive and easy to use, even in the most resource-poor environments and by technologynaïve users. The preprogrammed spreadsheet can be downloaded free of charge from the SCCM website,5 and a link to an instructional video is also available on the site.6 Current Implementations

The first worksheet in the spreadsheet (Figure 1) lists the guideline’s 24 recommendations and prompts users to complete a brief questionnaire about how frequently their users’ ICU implements each individual recommendation. Answer choices (ie, “nearly always,” “usually,” “sometimes,” or “nearly never”) are available via drop-down menus. Each response is assigned a number of “frequency points,” with higher point values given to recommendations that are not implemented frequently (ie, nearly always = 0, usually = 1, sometimes = 5, and nearly never = 10). “Not applicable” is available as a choice for certain recommendations (eg, those that apply only to neonatal ICUs). The first worksheet also incorporates a separate, predetermined set of scores—outcome points—to help users further prioritize recommendations that are infrequently (or never) implemented in their ICU and target


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Figure 2: Partial screenshot of the second worksheet in the gap analysis tool. The table has been auto-populated based on responses shown in Figure 1. The gap analysis tool auto-populates the top 5 recommendations in need of practice change from the ﬁrst worksheet into the second worksheet. Abbreviation: ICU, intensive care unit.

higher-impact outcomes as determined by the FCC guidelines writing group and a team of patient and family informants. This “outcome points” value is assigned based on the importance of the particular outcome(s) that the recommendation targets: family psychological symptoms = 5 points, quality of communication and trust in clinicians = 4, family satisfaction with care and communication = 3, clinician-rated quality of dying = 2, ICU and hospital use = 1.2 A higher outcome points value indicates a more important outcome. For example, if the research indicates that a particular recommendation improves psychological symptoms among families, that recommendation is preweighted with more outcome points (5) than another recommendation that only saves clinician time (1). The spreadsheet is formulated to multiply each recommendation’s outcome points value by its assigned frequency points’ value. The resulting “item score” value ranges from 0 to 50, with higher scores indicating a greater need for a practice change. This scoring system prioritizes recommendations that are currently infrequently (or never) implemented over those that are already implemented to some extent, even if the infrequently implemented recommendations happen to target a lower-priority outcome (Figure 1). Based on the item score value, the spreadsheet sets an “item rank” for each recommendation, with item rank 1 representing the recommendation that is most likely in need of implementation, item rank 2 representing the recommendation that is next likely in need of implementation, and so on.

auto-populated in a table on the second worksheet (Figure 2). This table makes up the first draft of a local FCC “bundle” or priority list for change. Users are directed to answer 2 questions for each selected recommendation: (1) How does your ICU differ from the guideline recommendation? and (2) What are the barriers to implementing the guideline recommendation? Checklists for possible common barriers are listed on the Table. The second worksheet is designed to facilitate discussions during ICU clinical team meetings and can be projected on a screen or printed and handed out. Based on the discussion generated from the results of the assessment questions, the ranking of the recommendations can be changed to reflect implementation priority and provide direction for ICU teams that want to implement successful high-yield projects. Before it was widely released, the FCC gap analysis tool was field tested at 6 different ICUs within the United States. On average, the initial questionnaire took 15 minutes for users to complete. The average discussions generated from the results took approximately 30 minutes. Feedback from the fieldtesting sites indicate that the tool would help an ICU’s leadership team prioritize areas of need and create an action plan to optimize family-centered care. Test users noted that they would recommend the tool to others. Furthermore, users found it important to read the guidelines completely before filling out the questionnaire of the gap analysis to fully understand the intent of each recommendation.

Practice Change Recommendations

Work Tools Document Proper assessment of existing practice versus best practice using a gap analysis strategy is important, but it is only the beginning of

Once users complete the questionnaire on the first worksheet, the top 5 recommendations in need of implementation are



the quality-improvement process. The new SCCM FCC guidelines cover a wide range of interventions, yet a significant amount of user effort is needed to fully embrace and implement the guidelines into daily workflows and unit cultures. Although the guidelines outline best practices, they do not suggest ways to implement each best practice recommendation. Awareness of relevant resources that already exist and that are widely available is thus key to implementing care improvement projects efficiently and to avoid “reinventing the wheel.” An 11-member SCCM task force comprising members of the FCC guidelines writing group and the SCCM Patient and Family Support Committee created an appendix to the new FCC guidelines. This document lists available work tools to assist with guideline recommendations.2 A link to the 9-page document can be found in the guidelines and on the SCCM website.5 These work tools are, broadly defined, resources that have been tested by others, are easily accessible, and give clinicians the step-by-step support needed to implement each recommendation. Although the task force attempted to find all of the available relevant tools for streamlining practice change, the appendix is not a definitive list. New work tools are continually tested and published, so users should not feel limited to using only the tools listed in the appendix. The task force located work tools by systemically reviewing the SCCM website and a number of key health care organizations’ websites that have well established interest and expertise in FCC (see Table). The references list from the FCC guidelines also were reviewed for possible links to implementation tools and strategies. As a final step, the work tools document was reviewed by all members of the FCC guidelines writing group and the Patient and Family Support Committee. Thought leaders in the field of FCC who have personal knowledge of the existence of relevant implementation tools are key members of both groups. The document’s resources are categorized under the same 5 domains as the recommendations: (1) family presence in the ICU, (2) family support, (3) communication with family members, (4) use of specific consultations and ICU team members, and (5) operational and environmental issues. Each resource listed


Table: Health Care Organizations With Work Tools for Implementing FCC in ICUs Organization Name Society of Critical Care Medicine Agency for Healthcare Research and Quality American Academy on Communication in Healthcare American Academy of Hospice and Palliative Medicine American Association of Critical-Care Nurses Institute for Healthcare Communication Institute for Patient- and Family-Centered Care Abbreviations: FCC, family-centered care; ICU, intensive care unit.

includes a brief description, its monetary cost (if applicable), and a link to the resource or to the most relevant reference in PubMed. Following, we have summarized a few of the work tools listed in the appendix. Family Presence in the ICU

The FCC guidelines advocate for a more open or flexible family presence at the patient’s bedside in the ICU. The work tools provided encourage family presence. “Better Together: Partnering With Families,” a North American campaign created through a partnership between the Institute for Patientand Family-Centered Care (IPFCC) and the Canadian Foundation for Healthcare Improvement (CFHI), aims to change the culture from seeing families as “visitors” in the ICU into one in which families are seen as “partners” in care within hospitals. The campaign’s free “change packet” outlines a sequential process for promoting family presence at the bedside and in participation with care.7 The American Association of Critical-Care Nurses (AACN) has released a number of related practice alerts in this domain. One of these alerts outlines the expected practice of appropriate open-family visitation policies in ICUs; another provides the basic framework for ICU nurses to initiate an action plan to help families be present during attempts at cardiopulmonary resuscitation. This framework also advocates that a staff member be assigned to support the family.8,9 Family Support

Family support recommendations are the most extensive recommendations found in the FCC guidelines. They include the consideration of family-education programs in the


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ICU, informational leaflets, ICU diaries, validated decision-support tools, and structured communication strategies during family meetings for patients with a poor prognosis. Among the work tools listed in the guidelines appendix are the following resources: • An article summarizing facilitated sensemaking—a theoretical framework for the provision of personalized instruction to families of patients about the ICU environment, interactions with staff, hospital services, participation in patient care, and self-reflection.10 • Links to leaflets that provide families with information about the ICU setting. Leaflets are from SCCM,11 the Neurocritical Care Society,12 AHRQ,13 and the Critical Care Innovations Group at the University of California in San Francisco.14 • Links to the Josie King Foundation,15 which sells ready-made journals created specifically for families of ICU patients. • Links to the ICU Diary Network,16 a networking site for health care providers interested in implementing diary programs in their local ICUs. • Information on how to access piloted paper-based “decision aids” for ICU surrogate decision makers working with clinicians to make key shared decisions (eg, deciding on whether to continue life support for patients with prolonged mechanical ventilation).2 • A downloadable pocket card from the University of Washington listing the components of the “VALUE” mnemonic (Value family statements, Acknowledge family emotions, Listen to families, Understand the patient as a person, Elicit family questions) for communicating with families in the ICU.17 Many of the FCC guidelines address the support of families of critically ill neonates. Relevant resources include the following: • Comforting Your Baby in Intensive Care, a booklet for parents to help them understand how to keep their neonate comfortable in the neonatal ICU18 • A link to the COPE for Hope website, an organization that, for a fee, provides on-site training for neonatal ICU staff on providing support for parents19 • A link to the Share Your Story website, an online peer-to-peer support community

for parents of critically ill neonates to share their experiences20 • A link to the downloadable MyPreemie App made available by Graham’s Foundation on multiple platforms21 that includes comprehensive information for families of premature babies and has a diary function Communication With Family Members

These FCC guidelines are based on 3 major communication recommendations: (1) the use of routine interdisciplinary family conferences, (2) the use of structured approaches when talking with families, and (3) formal communication training for ICU clinicians. Many health care organizations have published detailed algorithms for the timing of family meetings and care bundles as well as quality measures that summarize specific goals for the care of families during patient admission. Relevant references for these reports are listed in the work tools document.2 In addition to the VALUE mnemonic found in the Family Support section, the work tools document lists other communication techniques that have been published in the literature, including the SPIKES mnemonic (Setting, Perception, Invitation, Knowledge, Empathy, Summary)22 for breaking bad news and the NURSE mnemonic (Name, Understand, Respect, Support, Explore)23 for expressing verbal empathy. The work tools document lists 6 health care organizations offering communication skills training programs.2 Many of these programs focus on skills particularly relevant to critical care, including the disclosure of poor prognosis and end-of-life care to families. Although most of these organizations charge a fee to access their communication courses, the courses are well established. The effort required to create a new communication training program may be considerable, thus ICU clinicians and leaders may wish to take advantage of these resources rather than creating new ones. Use of Specific Consultations and ICU Team Members

In addition to recommending the availability of proactive palliative care consultations, ethics consultations when appropriate, the presence of social workers at family meetings, and spiritual support, the FCC guidelines promote



the use of a “family navigator,” which is a specially trained nurse or social worker who is assigned to families throughout the patient’s stay in the ICU and whose goal is to alleviate families’ psychological distress by helping to coordinate care and communicate with the ICU team. Intensive care units that want to start their own family navigator program will find a reference in the work tools document outlining how a pilot program of “communication facilitators” was developed and evaluated by a group of researchers in the Seattle area.24 The guidelines also recommend a psychologist’s intervention for mothers of preterm babies admitted to the neonatal ICU. The work tool document includes a detailed table of contents for a psychologist’s manual that has a step-by-step multimodal cognitive behavioral technique-based approach to reduce traumatic stress among neonatal ICU mothers.25 Operational and Environmental Issues

The FCC guidelines make several general recommendations about ICU operations and the ICU environment, including the implementation of protocols for sedation and analgesia during the withdrawal of life support, the involvement of nurses in goalsof-care decision-making, and the reduction of noise inside the ICU. The work tools document includes the following: • A set of orders used at the University of Washington when withdrawing life support for adult ICU patients26 • A training manual for the implementation of communication skills workshops for nurses that was made available by IMPACT-ICU (Integrating Multidisciplinary Palliative Care into the ICU), a University of California academic health centers’ program that is designed to integrate palliative care into the ICU through the use of bedside nurses27 • Weblinks to guidelines outlining the optimal design for adult28 and newborn29 ICUs and how to provide a quiet environment in the ICU The Institute for Patient- and FamilyCentered Care also has created operational guides for hospital-level leadership on how to promote family-centered care, including a How to Get Started guide for building partnerships


with patients and families and a Strategies for Leadership guide that includes a hospital self-assessment inventory.30 For a small fee, other self-assessment tools are available for leaders of adult and neonatal ICUs.31 Conclusion The SCCM FCC guidelines include a set of accompanying documents that are designed to help ICUs with evidence-based practice change. Both the gap analysis tool, which helps ICU clinicians identify areas of need, and the work tools document appendix, which summarizes available resources for FCC implementation, were designed to streamline the change process. Practice guidelines are often published with a required bundle or checklist to assess adherence to listed recommendations. The FCC guidelines writing group recognized that ICU units’ resources vary greatly, and thus the tools created to develop localized unitor organization-specific priority lists take into account current practice and local barriers to change. As ICU leaders and local FCC champions select implementation projects that are appropriate to their units’ climates and resources, practice change may occur on a faster timeline, with the ultimate goal of optimizing outcomes and advancing the field of family-centered care. ACKNOWLEDGEMENTS

The authors acknowledge the SCCM FCC Guidelines Writing Group, the SCCM FCC Guidelines Work Tools Task Force, and the SCCM FCC Guidelines Gap Analysis Tool Task Force for their contributions to the tools described in this manuscript. The information in this article was presented as a paper at the SCCM Critical Care Congress, Honolulu, Hawaii, January 25, 2017.

REFERENCES 1. Davidson JE, Powers K, Hedayat KM, et al. Clinical practice guidelines for support of the family in the patientcentered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005. Crit Care Med. 2007;35(2):605-622. 2. Davidson JE, Aslakson RA, Long AC, et al. Guidelines for family-centered care in the neonatal, pediatric, and adult ICU. Crit Care Med. 2017;45(1):103-128. 3. Gagliardi AR, Brouwers MC. Do guidelines offer implementation advice to target users? A systematic review of guideline applicability. BMJ Open. 2015;5(2):e007047. doi:10.1136/bmjopen-2014-007047. 4. AHRQ quality indicators toolkit for hospitals, 2014. Agency for Healthcare Research and Quality (AHRQ).


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5. 6.

7.

8.

9.

10.

11. 12.

13.

14. 15. 16. 17.


https://archive.ahrq.gov/professionals/systems/hospital /qitoolkit/qiroadmap.html#implementing. Updated October 2014. Accessed March 30, 2017. Guidelines. SCCM website. http://www.sccm.org /Research/Guidelines/Pages/Guidelines.aspx. Accessed March 30, 2017. SCCM website. Family-centered care guidelines – gap analysis tool instructional video [webcast]. https: //www.youtube.com/watch?v=gpxvGnTgm-I&feature= youtu.be. Accessed March 30, 2017. Canadian Foundation for Healthcare Improvement. Better together: partnering with families campaign. http://www.cfhi-fcass.ca/WhatWeDo/better-together /resources. Accessed March 30, 2017. American Association of Critical-Care Nurses. Practice alert: family presence: visitation in the adult ICU, 2016. https://www.aacn.org/clinical-resources/practice-alerts /family-presence-visitation-in-the-adult-icu. Updated 2016. Accessed March 30, 2017. American Association of Critical-Care Nurses. Practice alert: family presence during resuscitation and invasive procedures, 2016. https://www.aacn.org/clinical-resources /practice-alerts/family-presence-during-resuscitationand-invasive-procedures. Updated 2016. Accessed March 30, 2017. Davidson JE, Daly BJ, Agan D, Brady NR, Higgins PA. Facilitated sensemaking: a feasibility study for the provision of a family support program in the intensive care unit. Crit Care Nurs Q. 2010;33(2):177-189. doi: 10.1097/CNQ.0b013e3181d91369. Society of Critical Care Medicine. What is critical care? http://www.myicucare.org/Pages/default.aspx. Accessed March 30, 2017. Neurocritical Care Society. Patient/family information & resource guide, 2016. https://www.pathlms.com/ncsondemand/courses/1654. Updated 2016. Accessed Accessed March 30, 2017. Agency for Healthcare Research and Quality. Guide to patient and family engagement in hospital quality and safety. http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/index.html. Updated June 2013. Accessed March 30, 2017. University of California San Francisco Critical Care Innovations Group (CCIG). http://criticalcareinnovationsgroup .org/. Accessed March 30, 2017. Josie King Foundation. http://josieking.org/. Accessed March 30, 2017. ICU-Diary.org. ICU-Diary, 2012. http://www.icu-diary .org/diary/start.html. Updated February 2012. Accessed March 30, 2017. University of Washington School of Medicine End-ofLife Care Research Program. Communication tools.

18.

19. 20. 21. 22. 23. 24.

25.

26. 27.

28. 29.

30.

31.

http://depts.washington.edu/eolcare/products/communication-tools. Accessed March 30, 2017. Franck LS. Comforting your baby in intensive care, 2013. UCSF Department of Family Health Care Nursing. http://familynursing.ucsf.edu/resources-parents. Accessed March 30, 2017. Cope for Hope. http://www.copeforhope.com/index.php. Accessed March 30, 2017. March of Dimes. Share your story. http://share.marchofdimes.org/. Updated November 29, 2016. Accessed April 6, 2017. Graham’s Foundation. The MyPreemie app for preemie parents. http://grahamsfoundation.org/mypreemie-app. Accessed March 30, 2017. Buckman R. How to Break Bad News: A Guide for Health Care Professionals. Baltimore, MD: Johns Hopkins University Press; 1992. Smith R. Patient-Centered Interviewing: An EvidenceBased Method. Philadelphia, PA: Lippincott Williams & Wilkins; 2002. Curtis JR, Ciechanowski PS, Downey L, et al. Development and evaluation of an interprofessional communication intervention to improve family outcomes in the ICU. Contemp Clin Trials. 2012;33(6):1245-1254. doi: 10.1016/j.cct.2012.06.010. Shaw RJ, Sweester CJ, St John N, et al. Prevention of postpartum traumatic stress in mothers with preterm infants: manual development and evaluation. Issues Ment Health Nurs. 2013;34(8):578-586. doi:10.3109/01612840.2013 .789943. Treece PD, Engelberg RA, Crowley L, et al. Evaluation of a standardized order form for the withdrawal of life support in the intensive care unit. Crit Care Med. 2004; 32(5):1141-1148. Anderson WG, Puntillo K, Barbour S, et al. The Integrating Multidisciplinary Palliative Care Into the ICU (IMPACT-ICU) Project Guide, 2015. https://ucsf.app.box. com/v/impacticuprojectguide. Accessed April 6, 2017. Thompson DR, Hamilton DK, Cadenhead CD, et al. Guidelines for intensive care unit design. Crit Care Med. 2012; 40(5):1586-1600. doi:10.1097/CCM.0b013e3182413bb2. White RD, Smith JA, Shepley MM. Committee to Establish Recommended Standards for Newborn ICU Design. Recommended standards for newborn ICU design, eighth edition. J Perinatol. 2013;33(Suppl 1):S2-S16. doi: 10.1038/jp.2013.10. Free downloads – tools/checklists. Institute for Patient- and Family-Centered Care. http://www.ipfcc .org/resources/downloads-tools.html. Updated September 1, 2016. Accessed March 30, 2017. Self-assessment tools. Institute for Patient- and FamilyCentered Care. http://www.ipfcc.org/resources/assessment.html. Accessed March 30, 2017.


Implementing Intensive Care Unit Family-Centered Care: Resources to Identify and Address Gaps David Y. Hwang, Robert El-Kareh and Judy E. Davidson AACN Adv Crit Care 2017;28 148-154 10.4037/aacnacc2017636 ©2017 American Association of Critical-Care Nurses Published online http://acc.aacnjournals.org/ Personal use only. For copyright permission information: http://acc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

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