Redesigning the neurocritical care unit to enhance family participation and improve outcomes
ABSTRACT
Emory University Hospital recently converted its neurocritical care unit into an environment that enhances involvement of the patient’s family. Each patient room now has an adjacent family area with comfortable accommodations for daytime and nighttime use. The new unit design, which drew from evidence on the impact of the physical environment on patient outcomes, facilitates better interactions between families and the medical team, and early studies show that patient satisfaction and staff satisfaction have increased. This article describes the impetus for and process of the unit redesign, as well as initial results and lessons learned.
FAMILY-CENTERED UNITS POSE CHALLENGES
Units that are designed for both patients and their families bring to the fore enormous issues that arise in the ICU daily. How does one care for patients and their families simultaneously? Our challenges have included the following, among others:
- Team rounding. Nobody was happy about inviting families to rounds. Training medical students and fellows with families in the room is a real paradigm shift and raises many controversial issues. Yet I feel that the family needs to be aware of what is going on, particularly because our patients often are intubated and sedated and cannot act as their own advocates.
- Nursing handoffs. Imagine a nurse operating six or seven intravenous pumps and trying to figure out medications while having a family member—or three or four members—“in her face” 24 hours a day.
- Urgent or frightening treatment. How do you deal with resuscitation? What if the family is right by the bedside: do you ask them to leave? What kind of support do they need?
We do not have all the answers to such problems. We are currently studying them and trying to figure out best practices.
SUCCESSES AND FUTURE DIRECTIONS
Emory’s neurosciences critical care unit won the 2008 ICU Design Citation Award from the Society of Critical Care Medicine, the American Association of Critical Care Nurses, and the American Institute of Architects Academy on Architecture for Health.
We are now beginning to look at outcomes resulting from the unit redesign, and they all are going in the right direction. ICU patient satisfaction and staff satisfaction have increased, according to self-assessments. Other outcomes being assessed are length of stay and benchmark parameters of quality.
We are currently piloting a staff-family simulation workshop that will train all 80 members of our ICU nursing staff, including fellows, residents, and other faculty, in the fundamentals of communication. Using a one-way mirror, a team of psychologists and experts in grief and posttraumatic stress will watch simulated conversations among staff and actors role-playing situations involving brain death, organ donation, and diagnoses involving high mortality.
Although the concept of care centered around the patient and his or her family seems as acceptable as motherhood and apple pie, there is enormous resistance to it, even from the most dedicated health care workers. The process was long and laborious: we spent about a year and a half preparing for it with a familycentered team and involved all sorts of charters and directors along the way. Starting the changes is the real challenge.
