Visits to intensive care unit patients: frequency, duration and impact on outocme

Visits to intensive care unit

patients – frequency, duration and impact on outcome

Thomas Eriksson and Ingegerd Bergbom

ABSTRACT

The issue of the presence of patients’ loved ones during their intensive care unit (ICU) stay is a frequently discussed topic among ICU staff. Today, ICU patients’ loved ones are seen as important for the care of the patient. There is a gap in knowledge and research concerning the frequency and duration of visits by loved ones and the effect of such visits on patient outcome. The aim of this study was to explore the frequency and duration of loved ones’ visits and whether or not such visits have an impact on patient outcome. A prospective, explorative observational study design was used. The sample included 198 ICU patients from a general ICU in Sweden.

Twenty-five per cent of the patients had no visitors whatsoever. Forty-seven per cent of the patients who had visitors had visits of

0
5 h/day, 36% had visits of between 0
6 and 2 h/day and 17% had visits of >2 h/day. The most frequent visitors were spouses and children. Significant differences between the groups were that the patients who had no visitors were older, had a shorter ICU stay, lower nine equivalents of nursing manpower score and more often lived alone. There were no significant differences in mortality and length of hospital stay over time. We could not establish that patients who had no visitors had a poorer outcome. Most of the older patients had no visitors, which indicates that elderly people may have a poorer social network; thus, there may be a greater need for professional caring relationships and care planning.

Key words: Critical care• ICU visiting • Mortality • LoS ICU • LoS hospital

INTRODUCTION

The issue of the presence and influence of patients’

loved ones during their intensive care unit (ICU) stay is a frequently discussed topic among ICU staff. Staff encounter a large number of patients and their loved ones as well as patients who have no visitors at all.

Nurses often find that patients who have no visitors are more vulnerable, especially when critically ill or seriously injured. Because of their experience, nurses are of the opinion that patients with no visitors have a poorer chance of survival, although this has not been proven by research. Lack of knowledge about the impact of visits on the patient’s health, recovery and survival may contribute to non-individualized nursing care.

Family structures in the Western world today are complicated; the core family unit composed of wife, husband and children is rare, new family structures are more common and the number of persons living alone is on the increase. People actively choose to live alone;

some may have an extensive network, whereas others have one or just a few persons, not necessarily relatives, who are very important to them (Maddox et al., 2001; Socialstyrelsen, 2001). It is assumed that the older a person is, the more likely loved ones and relatives are to have disappeared from their life.

In this article, loved ones are defined as persons in the patients’ social network who are crucial or sig- nificant for them and with whom they have a positive emotional relationship. Such persons may be relatives, close family members, spouses, partners and friends or even a neighbour or a colleague. The most important criterion is that the patient describes them as loved ones (Robb, 1998).

One may assume that the quality of the relationship prior to the critical injury/disease is crucial. ICU professionals are unable to classify visitors in that way; thus, they have to rely on the word of the visitor when patients are not able to communicate or are Authors: T Eriksson, RN, CCRN, RNT, MScN, Clinical Nurse Specialist,

Doctoral student, CIVA/96, Sahlgrenska University Hospital, Go¨teborg, Sweden, and Institute of Health and Care Sciences, The Sahlgrenska Academy, Go¨teborg University, Go¨teborg, Sweden; I Bergbom, RN, RNT, PhD, Professor, Institute of Health and Care Sciences, The Sahlgrenska Academy, Go¨teborg University, Go¨teborg, Sweden

Address for correspondence: T Eriksson, CIVA/96, Sahlgrenska Universitetssjukhuset, SE 413 45 Go¨teborg, Sweden

E-mail: thomas.eriksson@vgregion.se

unconscious. It is impossible for staff to assess the quality of the relationship between the visitor and the patient. However, sometimes, patients’ reactions may give rise to the impression that the visit has a certain affect on them.

ICU patients’ perspective

Several interview studies (Bergbom and Askvall, 2000;

Hupcey and Zimmerman, 2000; Granberg-Axe´ll, 2001;

Magarey and McCutcheon, 2005) have shown that loved ones have a major impact on patients in an ICU.

The loved ones help the patients to remain in touch with reality and give them hope and strength to struggle against critical illness or injuries. Patients reported that relatives were even more important than professional carers. Patients who survived critical illness related that their love for their partner became deeper and closer, and they described their partner as their lifeline (Maddox et al., 2001). But whether this affects patients’ survival is not clear and remains to be investigated.

ICU mortality

There are several factors that can have an influence on the quality of care, survival rate and the patients’

condition and reactions. According to the research by Kva˚le (2004), patients cared for in ICUs have a poorer outcome compared with a normal population in up to 10 years after discharge. Large studies have found that average ICU mortality is in the range of 10%–22%, whereas hospital mortality (including ICU mortality) is normally around 20%–33% (Niskanen et al., 1996;

Goldhill and Sumner, 1998; Kva˚le, 2004). In a recently published review (Williams et al., 2005), ICU and hospital mortality rates ranged from 8% to 33% and from 11% to 64%, respectively. However, differences in design, methodology and reporting make interpreta- tion and comparison difficult.

ICU visits

There have been many changes in ICU visiting policies, from a total ban to open visiting hours (Marco et al., 2006). Simpson (1991) developed an instrument and interviewed 50 ICU patients about their preferences on the subject of visiting times. Gonzalez et al. (2004) used the instrument of Simpson in a study comprising 30 ICU patients. They found that visits were not stressful for the patients and did not lead to less rest or increased pain. We found no studies that explored whether loved ones’ visits or presence during the patient’s ICU stay are significant for patient outcome related to mortality and whether the frequency and length of the visit have an impact on patients’ experiences and mortality.

AIM

The aim of the present study was to explore the frequency and duration of loved ones’ visits to mechanically ventilated patients at a general ICU. An additional aim was to investigate whether such visits had an impact on patient survival and length of stay (LoS) in both ICU and hospital as well as survival at 1, 3 and 6 months after discharge from the ICU.

METHOD

A prospective, explorative, observational design was used. Data were collected from a university hospital in Western Sweden, with a regional referral area covering approximately 1
5 million inhabitants. The ICU has 12 beds and admits adult patients with medical and surgical conditions and trauma. The unit has flexible visiting hours; the ICU nurse decides whether or not visits are appropriate based on the patient’s condition and the care situation. The ICU policy recommends that visits should take place in the afternoon and evening. Most nurses try to reach an agreement on visiting times with the patient’s loved ones. Children of all ages are welcome without restrictions.

Sample

The patients included in the study met the following criteria: 18 years old, acute admittance as a result of critical illness/serious injuries, with an ICU stay of

48 h and mechanically ventilated for 24 h. This period was chosen to ensure that there was sufficient time to visit the patient, as the referral area is wide.

Patients with head injuries, psychiatric diagnosis and intoxication were excluded from the study. Patients were only included on first admission. The eligibility criteria were set because of the design of the overall project, of which this is the first of four studies. We were interested in interviewing the group of acutely admitted patients who had no opportunity to prepare themselves for the event, in addition to those who were sedated and unconscious. The interviews were con- ducted after their discharge from the ICU.

Data collection

Data collection took place over an 8-month period, starting in March 2004, and was carried out by T. E.

During that time, total admissions amounted to 1115 patients, of which 198 fulfilled the inclusion criteria and were therefore included (Figure 1).

All ICU admissions were recorded electronically in a database, from which data were extracted about gender, age, reason for admission and LoS in ICU, acute physiology and chronic health evaluation (APACHE II) (Knaus et al., 1985), nine equivalents

of nursing manpower score (NEMS) (Reis Miranda et al., 1997), duration of mechanical ventilation and ICU mortality. The mortality rate at 1, 3 and 6 months after discharge from the ICU was drawn from the hospital database. Social factors such as civil status, visiting frequencies, duration and relationship to visitor were derived from the ICU observational sheet.

The study was performed in accordance with the Helsinki Declaration and approval obtained from the university ethics committee and from the chief phy- sician in the ICU where the study took place.

Data analysis

Statistical analyses were performed by means of the Statistical Package for Social Sciences, version 12.

Descriptive statistics were used for presenting demo- graphic data. Continuous variables are shown in the form of mean and standard deviation, whereas categorical data are shown as figures and percentages.

The patients were divided into two groups, one who received visits during the ICU stay and the other who had no visitors. Focus was on an assessment of the impact of the differences between the two groups. The material was dichotomized and compared using Fisher’s exact test. The first analysis of paired asso- ciations between the survival variable and the explan- atory variables shows statistically significant differences in age, APACHE II, endotracheal tubing time and LoS hospital variables associated with survival. To analyse whether the significance was stable or a statistical coincidence, we used a maximum likelihood model to test all paired significant factors, i.e. a logistic regres- sion analysis (Altman, 1995; Bewick et al., 2005). The

significant variables were included, and the visiting variable was treated as an explanatory variable show- ing no significant differences. We performed a second analysis as described above to establish whether or not there were differences if the visitor variable was treated as an explanatory variable. The statistical tests were considered significant if the critical level was less than 5% (p < 0
05).

RESULTS

The study population consisted of 198 subjects, 132 (67%) men and 66 (33%) women. The mean age was 63 ± 9
8 years, and APACHE II was 20
7 ± 8
6. The patients were cared for in the ICU for an average of 9
9 ± 9
8 days and in hospital (including LoS in the ICU) for 34
3 ± 31
5 days. Demographic and medical treatment data as well as the outcome for all patients are shown in Table 1.

The most common reasons for ICU admissions were diseases of the digestive system, 48 (24%); circulatory system, 45 (23%) and respiratory system, 33 (17%) (Figure 2).

Visitors

Fifty (25%) patients had no visitors whatsoever during their ICU stay, whereas 148 (75%) had visitors. The most frequent visitor was the patient’s spouse, either alone (23%) or accompanied by the patient’s children (20%). Eleven per cent of the visitors were children and 8% cohabiting partners. Only 6% of the visitors were parents, whereas 4% other relatives and 3% friends.

There were no statistically significant differences between the groups with and those without visitors in relation to mortality and hospital LoS. Patients

148 with visitors

50 without visitors 198

met inclusion critieria

348 (38%) no mechanical

ventilation

165 (18%) planned admission

128 (14%) admission for

<48 h

92 (10%) neurological, psychological diagnosis

92 (10%) intoxication

92 (10%) death <48 h 917

exluded 1115 admissions

to ICU during the study period

Figure 1 Description of the total number of patients admitted to the ICU and reason for exclusion from the study. ICU, intensive care unit.

without visitors were significantly older, more likely to be female, had a lower NEMS score, had rarely undergone tracheotomy, were more likely to live alone and had a shorter LoS in the ICU than those who received visits (group 1) (Table 2). There were no significant differences between the two groups in terms of diagnosis on admission (Figure 2). The only

exploratory factor that was important when conduct- ing logistic regression was age.

Frequency and duration of visits

Frequency of visits was, on average, 9 ± 12
8 h during the ICU stay, with a mean duration of 13
35 ± 21 h. The minimum was 15 min on a single occasion, whereas the maximum being 153 h, with a frequency of 84 visits during the ICU stay. This shows that the range is wide, from 15 min on a single occasion to the loved one remaining at the patient’s bedside for more or less the whole time that the patient was in the ICU. The median is 5 h and four visits, and the 75th percentile is 14 h and 10 visits. Another way of describing this is to transform data to hours and visits per day, which shows a range from 0
7 occasions of a 1
3-h duration to a maximum of three visits of a 19-h duration in the course of 1 day.

Nearly half of the patients who had visitors (47%, n = 70) had a visit duration of  0
5 h/day, 36% (n = 53) had visit duration of between 0
6 and 2 h/day and 17%

(n = 25) had visit duration of >2 h/day.

Single people have fewer visits than those who live with a partner (p = 0
021). Male patients received more visits than female patients (p = 0
023). The group of patients who had been on mechanical ventilation for >9 days (p = 0
0001) or been endotracheally intubated for

>5 days (p = 0
0035) received significantly longer visits.

The LoS in the ICU was one factor that increased the Table 1 Some demographic and medical treatment data as well as

patient outcomes sample

Characteristics All patients (n = 198)

Men, n (%) 132 (67)

Women, n (%) 66 (33)

Mean age in years (SD) 62
7 (9
8)

APACHE II score on admission (SD) 20
7 (8
6)

NEMS (SD) 318 (332)

Mechanical ventilator, days (SD) 7
6 (8
8) Endotracheal tube, days (SD) 4
3 (4)

Tracheotomy, days (SD) 3
3 (7
4)

Complications, n (%) 38 (19)

Mean LoS in ICU, days (SD) 9
9 (9
8)

Mean LoS in hospital, days (SD) 34
3 (31
5)

ICU mortality rate, n (%) 26 (13
1)

Hospital mortality rate, n (%) 32 (16
2)

Living alone, n (%) 73 (36
8)

No children, n (%) 77 (38
9)

APACHE II, acute physiology and chronic health evaluation; ICU, intensive care unit; LoS, length of stay; NEMS, nine equivalents of nursing manpower score.

Haemorrhage NOS Complications of surgical and medical care Burns and corrosions Trauma Diseases of the urinary system Certain disorders involving the immune mechanism Diseases of the digestive system Diseases of the respiratory system Diseases of the circulatory system Diseases of the nervous system Shock Disorders of fluid, electrolyte and acid–base balance Endocrine, nutritional and metabolic diseases Diseases of the blood and blood-forming organs Neoplasms Certain infectious and parasitic diseases

25·0%

20·0%

15·0%

10·0%

5·0%

0·0%

Figure 2 Diagnosis on admission to the intensive care unit.

frequency and duration of visits in patients who spent

>7 days in the ICU (p = 0
0001).

Mortality

To measure mortality over time, we conducted follow ups of patients’ survival and mortality over a 6-month period, i.e. at 1, 3 and 6 months, using the hospital database, which is connected to the National Registra- tion System in Sweden. As shown in Table 3, there were no significant differences in survival and mortal- ity between those with and those without visitors. In this study, ICU and hospital mortality rates were 13%

and 16%, respectively, thus a total mortality rate of 29%. The inclusion of the 4% of patients who died after discharge from the hospital during the 6-month period following their ICU stay leads to a mortality rate of 33%. No patients from the group without visitors died in 1–3 months after discharge (Table 3). In group 1, 3%

(n = 5) of patients died after discharge from hospital compared with 6% (n = 3) in group 2.

DISCUSSION

The overall aim of the present study was to illuminate the situation in a general ICU concerning the frequency and duration of visits to patients by their loved ones.

An additional aim was to explore whether the visits or the lack of visits by the loved ones affected the LoS in the ICU and hospital as well as mortality at 1, 3 and 6 months after discharge, which led to the choice of an exploratory design.

There are some methodological limitations. The number of patients in the two groups was not identical, and the data were collected from one ICU. Neverthe- less, it is plausible that similar results could be found at other university hospitals but maybe not in regional hospitals, as the latter are located closer to patients’

homes and loved ones. These facts could have an impact on the frequency and duration of visits. An additional data item ‘distance from home’ may have illuminated this issue. In their study, Gonzalez et al.

(2004) found that patients preferred visits on three to four occasions per day, with a duration of 35–55 min and a maximum of three visitors at any one time. In our study, we found that 83% had visits of 2 h/day, whereas only 17% had visits of >2 h/day.

This study found no evidence to suggest that visits from loved ones shortened LoS in the ICU or hospital or reduced the mortality rate. One explanation could be the patients’ condition. Patients who had no visitors had a significantly shorter LoS in the ICU, i.e. they did not require critical care to the same extent as that required by those with a longer LoS. On the other hand, they had the same APACHE II score on admission, and there were no significant differences between the two groups in terms of diagnosis on admission. Overall, the LoS in the ICU in this study is fairly long, with a mean of 6 days compared with the average for a Swedish ICU patient of 57
8 h (2
4 days) during 2004 (Nolin and Ma˚rdh, 2005). To use NEMS to explain the findings is not helpful because of the fact that it is related to the LoS and there is a correlation between LoS in the ICU Table 2 Demographic, medical and outcome data for patients in the two

groups

Characteristics

Group 1 patients (with visitors), n = 148)

Group 2 patients (without visitors),

n = 50) p value

Men, n (%) 105 (71) 27 (54) 0
037

Women, n (%) 43 (29) 23 (46) 0
04

Mean age in years (SD)

60
9 (15
9) 68
1 (14
4) 0
0014

APACHE II score on admission (SD)

20
7 (8
7) 20
7 (8
1) 0
87

NEMS (SD) 366 (358) 176 (176) 0
00058

Mechanical ventilator, days (SD)

8
9 (9
6) 3
7 (4
4) 0
19

Endotracheal tube, days (SD)

4
7 (4
4) 3
3 (2
6) 0
22

Tracheotomy, days (SD) 4
3 (8
2) 0
5 (2
5) 0
0488

Complications, n (%) 32 (22) 6 (12) 0
096

Mean LoS in ICU, days (SD)

11
3 (10
5) 5
6 (5
3) 0
0004

Mean LoS in hospital, days (SD)

35
6 (32
7) 30
5 (27
8) 0
74

ICU mortality rate, n (%)

19 (12
8) 7 (14) 0
13

Hospital mortality rate, n (%)

24 (16
2) 6 (12) 0
16

Living alone, n (%) 48 (32
4) 25 (50) 0
021 No children, n (%) 53 (35
8) 24 (48) 0
08 APACHE II, acute physiology and chronic health evaluation; ICU, intensive care unit; LoS, length of stay; NEMS, nine equivalents of nursing manpower score.

Table 3 Survival in the ICU and 1, 3 and 6 months after discharge from the ICU

Survival in the ICU

Survival at 1 month

Survival at 3 months

Survival at 6 months Group 1 patients

(with visitors), n (%)

129 (87) 114 (77) 105 (71) 98 (67)

Group 2 patients (without visitors), n (%)

43 (86) 37 (74) 37 (74) 34 (68)

Total, n (%) 172 (87) 151 (76) 142 (72) 132 (67) ICU, intensive care unit.

and the NEMS (Reis Miranda et al., 1997). There were no significant differences between patients in the two groups in relation to complications during the ICU stay. The exploratory variable for a higher mortality rate in this study is age (p = 0
0014), i.e. the patients are older and live alone. This result is in accordance with the findings of Somme et al. (2003).

The discourse today about the outcome after ICU discharge focuses on long-term survival and quality of life (Kva˚le, 2004). Therefore, attention must be devoted to care during the ICU stay and also to what happens to the patient after discharge from the ICU and if and how the health care system takes care of patients and their families following an ICU stay as a result of serious illness (Jones et al., 2003).

One way to achieve this is to provide family-centred care both in ICUs and during the recovery period.

Providing such care means that the team members are aware of their responsibility to help the family and the patient to cope with the crisis brought about by an illness. Family-centred care is a philosophical approach to provide care for patients and their families. The basic premise of this philosophy is that patients are part of a larger ‘whole’ and that the team must be aware of this fact if they are to provide the best possible care.

Such care requires a collaborative approach in which all team members support and embrace the philosophy (Henneman and Cardin, 2002).

One aim of the present study was to investigate whether no visits resulted in higher mortality. Despite

the use of empirical analytic methodology, the varia- bles chosen failed to show significant findings probably because of the complexity of the issue. Interviews with patients and their loved ones is one way to deepen the understanding about questions such as: What do ICU patients experience when their loved ones visit them?

What do such visits mean to the patients and their outlook on life, including the meaning of life and suffering, after being cared for in an ICU?

CONCLUSIONS

The findings of this study support previous studies (Simpson, 1991, 1993; Gonzalez et al., 2004) in which patients described their preferences in terms of visits.

Our results are almost identical with regards to the frequency and duration of visits from loved ones. In the group which had visitors (n = 148), 47% (n = 70) had visits lasting 0
5 h/day, whereas 17% (n = 25) had visits lasting >2 h/day.

In this study, 25% (n = 50) of the patients did not have any visitors whatsoever. We found no evidence to suggest that patients who received no visits from loved ones had a poorer outcome. The significant differences are that the patients without visitors were older, had a shorter LoS in the ICU, lower NEMS scores and more often lived alone. This may indicate that the care provided in the ICU should/could consider other care strategies. There is a need for further research to investigate and illuminate the needs of patients who have no visitors during their ICU stay.

WHAT IS KNOWN ABOUT THIS TOPIC

• Research has shown that loved ones have a major impact on patients in an ICU.

• Patients preferred three to four visits of a duration of 35–55 min/day, with no more than three visitors at a time.

• Average ICU mortality rate is 10%–22%, whereas hospital mortality rate (including ICU mortality) is approximately 20%–33%.

WHAT THIS PAPER ADDS

• Twenty-five per cent of the ICU patients had no visitors and these patients were generally older and more often lived alone.

• No increase in mortality was observed among patients who had no visitors during their ICU stay.

• Forty-seven per cent of the patients who had visitors had visits of 0
5 h/day, 36% has visits of between 0
6 and 2 h/day and 17% had visits of >2 h/day.

• The most frequent visitor was the patient’s spouse, either alone (23%) or accompanied by the patient’s children (20%).

• Women have fewer visitors than men.

REFERENCES

Altman DG. (1995). Practical Statistics for Medical Research.

London: Chapman & Hall.

Bergbom I, Askvall A. (2000). The nearest and dearest: a life- line for ICU patients. Intensive & Critical Care Nursing; 16:

384–395.

Bewick V, Cheek L, Ball J. (2005). Statistics review 14: logistic regression. Critical Care; 9: 112–118.

Goldhill R, Sumner A. (1998). Outcome of intensive care patients in a group of British intensive care units. Critical Care Medicine; 26: 1337–1345.

Gonzalez C, Carroll D, Elliott J, Fitzgerald P, Vallent H. (2004).

Visiting preferences of patients in the intensive care unit and complex care medical unit. American Journal of Critical Care;

13:194–197.

Granberg-Axe´ll A. (2001). The Intensive Care Unit Syndrome/

Delirium, Patients’ Perspective and Clinical Signs. Unpublished Doctoral dissertation, Lund University, Lund.

Henneman E, Cardin S. (2002). Family-centered critical care:

a practical approach to making it happen. Critical Care Nurse;

22:12–19.

Hupcey J, Zimmerman H. (2000). The need to know: experiences of critically ill patients. American Journal of Critical Care; 9:

192–198.

Jones C, Skirrow P, Griffiths R, Humphris G, Ingleby S, Eddleston J, Waldmann C & Gager M. (2003). Rehabilitation after critical illness: a randomized, controlled trial. Critical Care Medicine;

31:2456–2461.

Knaus W, Draper E, Wagner D, Zimmerman J. (1985). APACHE II: a severity of disease classification system. Critical Care Medicine; 13: 818–829.

Kva˚le R. (2004). Long-term Outcomes after Intensive Care. Unpub- lished Doctoral dissertation, University of Bergen, Bergen.

Maddox M, Dunn SV, Pretty LE. (2001). Psychosocial recovery following ICU: experiences and influences upon discharge to the community. Intensive & Critical Care Nursing; 17: 6–15.

Magarey J, McCutcheon H. (2005). ‘‘Fishing with the dead’’ – recall of memories from the ICU. Intensive & Critical Care Nursing; 21: 344–354.

Marco L, Bermejillo I, Garayalde N, Sarrate I, Margall A, Asiain C. (2006). Intensive care nurses’ beliefs and attitudes towards

the effect of open visiting on patients, family and nurses.

Nursing in Critical Care; 11: 33–41.

Niskanen MF, Kari A, Halonen P. (1996). Five-year survival after intensive care – comparison of 12180 patients with the general population. Finnish ICU Study Group. Critical Care Medicine; 24: 1962–1967.

Nolin T, Ma˚rdh C. (2005). Swedish Intensive Care Register. Annual report 2004. (Svenska Intensivva˚rdsregistret – SIR. A˚ rsrapport 2004). http://www.icuregswe.org (accessed 31/1/06).

Reis Miranda D, Moreno R, Iapichino G. (1997). Nine equivalents of nursing manpower score (NEMS). Intensive Care Medicine;

23:760–765.

Robb YA. (1998). Family nursing in intensive care, part one: is family nursing appropriate in intensive care? Intensive &

Critical Care Nursing; 14: 107–158.

Simpson T. (1991). Critical care patients’ perceptions of visits.

Heart & Lung; 20: 681–688.

Simpson T. (1993). Visit preferences of middle-age vs older critically ill patients. American Journal of Critical Care; 2:

339–345.

Socialstyrelsen. (2001). Social Report 2001 (Social rapport 2001). The National Swedish Board of Health and Welfare: Stockholm, Sweden.

Somme D, Maillet J, Gisselbrecht M, Novara A, Ract C, Fagon J.

(2003). Critically ill old and the oldest-old patients in intensive care: short- and long-term outcomes. Intensive Care Medicine; 29: 2137–2143.

Williams TA, Dobb GJ, Finn JC, Webb SA. (2005). Long-term survival from intensive care: a review. Intensive Care Medicine;

31:1306–1315.