Researchers try to make ICU less traumatic for patients, families

Intensive care units (ICUs) can be extremely stressful for patients and families. Changes in the way ICUs are run may help mitigate that stress, two new studies suggest.

Researchers looking at the impact of making ICU visiting hours more flexible, and the keeping of ICU diaries by staff and family members, found some interventions could, at the very least, lessen stress for families, according to the two reports published in JAMA.

“The efforts made by the researchers are admirable,” said Dr Albert Wu, an internist and professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health who was not involved in either study. “But I think this is just a drop in the ocean. The ICU experience is so profoundly disorienting, especially for patients, but also for family members and even, to some extent, the people providing the care.”

The visitation study was originally designed to see if longer visiting hours might help prevent delirium in ICU patients. They didn’t - but they did appear to lower anxiety and depression in relatives.

In that study, the number of visitation hours in 36 adult ICUs in Brazil was expanded from a maximum of 4.5 hours a day to 12 hours a day. From June 2017 to June 2018, 1,685 patients were randomly assigned to the shorter or more flexible visitation schedules.

Average duration of visits was longer in the group with a 12-hour window for visitation: 4.8 hours versus 1.4. And while patient delirium wasn’t reduced with the longer hours, anxiety and depression levels in the family members declined significantly.

“Although a flexible visiting policy for ICUs has been recommended by professional society guidelines, the evidence suggests most ICUs adopt restrictive visitation models, possibly motivated by risks . . . such as disorganization of care, infections and staff burnout,” said the study’s lead author, Dr Regis Goulart Rosa of Hospital Moinhos de Vento, Porto Alegre, Brazil. “Interestingly these risks were not confirmed in the ICU visits study.”

The longer, flexible, visiting hours offer a host of benefits: “for patients, the benefits of reassurance, emotional support and comfort, for family members the opportunity to help a loved one,” Rosa said.

The diary study followed 657 ICU patients in France, ages 51 to 70, who were on mechanical ventilators for at least two days, plus one family member for each patient. The study’s main goal was to determine whether a patient diary filled out by staff and family members could curb posttraumatic stress disorder (PTSD) in patients and families.

Patients were randomly assigned to have diaries or not. Before they left the ICU, they - or family members, if the patient was confused - were given the diary to read. If the patient died, the diary was sent to the family with a condolence note.

Three months later, patients and families were interviewed by a psychologist who was unaware of which group they’d been assigned to.

Ultimately, 339 patients completed the trial, with 29.9% of the diary group experiencing PTSD symptoms, as compared to 34.3% of the control group. While there was a difference, it wasn’t large enough for the researchers to be sure it wasn’t by chance. There was also no significant difference between the groups of relatives, more of whom scored higher on PTSD symptoms than the patients themselves.

There are several possible reasons why the diaries didn’t make a big impact on PTSD rates, Dr Maite Garrouste-Orgeas, an internist at the Hopital Franco-Britannique, and colleagues noted in their report. One might be that the study “was not focused on high-risk patients who may have different needs,” they suggested.

For patients, being in the ICU “is a frightening, painful, bewildering and disorienting experience,” Wu said. “They are subjected to all sorts of things they don’t understand that can be painful and traumatic. Some people have described the experience as tortuous.”

Some centers are experimenting with ways to make the experience less traumatic, Wu said. ICUs tend to be completely shut in with no natural light for indefinite periods of time, he added. “Something that is being done here and elsewhere is to put skylights and even windows in the ICU so when patients are awake they can experience the day/night cycle and see a bit of the sky and green.”

Making the experience less traumatic for families is also important since they are the people who will be caring for the patient after discharge, Wu said.