Open-door ICUs can help patients but are mixed bag

How accessible should you make your critical care unit? Some nurse managers and physicians are beginning to question whether keeping the ICU out of the reach of patients’ families and their personal physicians is a good idea. Others aren’t certain.

The answer seems to rest on certain factors, including the physical size of the unit and the level of commitment of the medical and nursing staff to unrestricted access, says Dianne Y. Daniels, RN, a nurse educator at the University of North Carolina’s College of Nursing in Charlotte.

The debate over open-door policies in the ICU has received attention mostly in discussions and seminars but hasn’t moved much beyond the speculation stage. Hospitals have toyed with the possibility of giving greater access to families of ICU patients in the belief that the longer contact could help improve outcomes and stabilize volatile medical conditions.

Is an open-door policy dangerous?

Most ICUs do allow restricted family visits on a selective basis. But in many cases, patients have been too ill for visits and 24-hour visiting policies have rarely, if ever, been considered practical in the ICU. Making a unit accessible to outsiders, even noncritical care physicians, 24 hours a day is regarded by most ICU mangers as meddlesome and possibly even dangerous to other critically ill patients.

But the open-model concept doesn’t stop at family visitations. In an unrelated approach, hospitals have long maintained an open organizational structure as a medical-care option. Under this model, ICUs routinely admit critically ill patients without formal triage. They also give unfettered access to the patient’s primary care physician.

According to researchers, several hospitals currently use an open organizational model in their ICUs. These same researchers advocate a closed setting as more cost efficient.1

Together, these two approaches to ICU care have been criticized because they tend to shift too much focus away from traditional critical care medical practices and place too much emphasis on "soft" ancillary resources. But they persist, mostly as a result of critical care medicine’s evolution toward more patient-centered strategies.

Supporters of open visitation are relatively few. But they’re rooted in the belief that "patients and their families can benefit from wider access in the ICU," says Daniels. She has written about open-visitation policies and says they can work at hospitals with relatively small ICUs and where charge nurses and other staff are adequately trained and highly customer service-oriented.

But if conditions are right, even unconscious terminally ill cases that are on ventilators and in the last throes of life could benefit from having families regularly at their bedsides, advocates say. In fact, these are patients and families who stand to benefit most in the last moments of life, proponents of open-door policies argue.

Nevertheless, administrators have drawn the line when it comes to such unrestricted policies.

Considering the human component

Underlying the discussion, however, supporters of open-model ICUs believe that quality patient care and cost containment can be achieved by maximizing the use of ancillary "human" resources such as family members and their physicians in critical care settings. Making allies of these noncritical care personnel can help lower the cost of ICU medicine while potentially improving outcomes, they say.

According to researchers at Long Island Jewish Medical Center in New Hyde Park, NY, lowering the cost of critical care has led to experimentation with different operating models. While ICUs generally account for only 5% to 10% of inpatient beds, they eat up about 34% of most hospital budgets. In 1990, the latest year in which figures were available, the cost of ICU care stood at $62 billion or 1% of the nation’s gross domestic product.

The aim has been to lower costs through various patient-care strategies. But ICUs are the one place in which cost-cutting options may be limited due to the intensity and duration of expensive resource utilization, according to one study of closed ICU models conducted by Jewish Medical Center earlier this year.1

But while cost-cutting is certainly important, open visitation policies are more focused on improving the quality of patient care in the ICU, not necessarily on achieving direct cost savings, observes Eileen Speed, RN, a staff nurse in the critical care unit of Presbyterian Hospital in Matthews, NC.

In 1994, Presbyterian took the unusual step of instituting an unrestricted 24-hour family visitation policy in its critical care unit. The policy allows family members the right to remain with relatives around the clock "as long as their presence doesn’t interfere with the patient’s stability or condition," Speed says.

The unit does set limits on certain occasions, particularly those involving cases of recent myocardial infarction or patients who are subject to volatility in their conditions. But these cases are in the minority. Most patients, especially the elderly, appear to do better when they are close to family members, Speed notes. The majority of patient cases in the ICU involves recent heart attack victims and serious orthopedic injuries. About 60% of patients in the six-bed unit are age 60 and older.

However, the hospital isn’t certain whether patients do better as a result of the open policy or if it only seems that way. Most of the perceptible gains with patients have been anecdotal, Speed acknowledges. But factual or not, the payoff has been visible to nurses by seeing quieter, more stable patients and fewer worried family members.

"The system saves us a lot of time making phone calls and having to explain things to anxious relatives," Speed says, which frees up nursing time and manpower. At first, physicians and some nurses resisted the idea. But after four years, most nurses have been sufficiently trained to carefully manage the visitations without seeming obtrusive and have accepted the policy as part of the medical care rendered in the unit.

But even Speed and Daniels acknowledge that conditions have to be right for these policies to flourish. These include:

o An appropriate physical infrastructure.

The ICU at Presbyterian is very small. At only six beds, it also has a relatively high nurse to patient staffing ratio (each shift has two full-time nurses in the unit), which helps in managing patients and families when they are together. The unit also has separate rooms for each patient, which makes around-the-clock visitations possible without interfering with other patients.

o An early adoption experience.

Hospital administration supported the ICU’s efforts early when the unit was established in 1994. Getting in at the outset has helped because administration officials had no history to fall back on as an indication that the plan would fail. They were also intent on making the unit work by trying innovative strategies, according to Daniels.

o A supportive nursing staff.

While they received no formal training, staff nurses saw the benefits of working with families and became receptive to the idea of focusing on patients’ emotional well-being in the ICU, Speed recalls. Without a unified, supportive nursing staff, the system would encounter mixed results, she adds.

But while Presbyterian’s efforts are noteworthy, are they effective? A different school of thought advocates that ICUs should not be open to outside influences. They should be closed models of medical care. Allowing limited family visitations is one thing, but permitting outsiders to play a significant role in influencing critical care outcomes and decision-making is another.

A recent study of closed ICU models didn’t go so far as to say so, but researchers found that closed settings tended to be more efficient from a patient utilization standpoint. They had lowered lengths of stays in both the ICU and in the hospital overall (6.1 ICU days in the closed setting compared to 9.3 days in open models and 22.2 overall hospital days vs. 31.2 days respectively).

Patients on ventilation support also had shorter periods of mechanical ventilation (3.3 days in the closed setting vs. 6.4 days in the open model). In calculating the differences for this part of the study, researchers looked at one hospital before and after it closed its ICU. Patient mortality was affected depending on the open or closed model, but the variability was considered small.

A closed ICU, according to the researchers, was defined as one in which the patient is transferred to the care of an intensivist and patients are accepted in the unit only after a complete clinical evaluation.1

One of the reasons cited for improved utilization was the possibility that in the closed ICU, most patients were transferred from the hospital’s emergency department after formal triage. This could have accounted for better, more targeted resource utilization.

In both cases, proponents of closed or open ICUs indicate that there are several variables in either case that account for eventual results. Nurse managers should consider them as options. But they should also investigate their suitability with knowledge and caution.

Reference

1. Multz AS, Chalfin DB, Samson IM, et al. A "closed" medical intensive care unit (MICU) improves resource utilization when compared with an "open" MICU. Am J Respir Crit Care Med 1998; 157:1,468-1,473.