Opening Up Visiting Hours In The ICU By Paul Levy

(Originally published on Bedside Manner at Everyday Health)
Like most people, I sometimes get tired of the sound of my own voice, or in the case of my blog, my own writing. I thought it would be interesting to invite some of my health care colleagues to share with my readers their take on compassionate health care. This week’s post is one in an occasional series of dispatches from other corners of the health care world.

Our guest blogger this week is Paul Levy, the CEO of Beth Israel Deaconess Medical Center. His blog, Running a Hospital, is one of the best and most well-read health care blogs around. While Paul writes about everything under the sun, one of the recurring themes in his blog, and one of the guiding principles of his professional life, is transparency: giving the public better access to information on the cost and quality of health care; he practices what he preaches. He doesn’t shy away from shining the light on his own hospital - even when mistakes are made.

I especially loved his entry about hospital CEO salaries, entitled, “Do I get paid too much?“

With no further ado, I give you Paul Levy.

Compassionate care often involves the manner in which we care for the loved ones of our patients. This is particularly the case in intensive care units.

It is easy, in the hubbub of ICUs, for the care delivery system to be designed to serve the work flows of the nurses, doctors, and respiratory therapists. While it is clearly important for those staff members to have immediate access to the patient to monitor conditions and respond to emergent circumstances, it is a mistake to assume that this must come at the expense of proper involvement of family members and close friends of the patient.

I wrote about this recently on my blog where I addressed the issue of visiting hours. It is hard to imagine an aspect of ICU care that creates more consternation for family members. They are nervous and anxious for their relative, and then they are told that they are not permitted to enter the ICU or must leave it by a certain time.

With the help of a family and patient advisory panel, an interdisciplinary group of the ICU medical staff at BIDMC decided to eliminate visiting hours. They decided that allowing loved ones to be in the ICU at all hours would actually be helpful to all parties. Since the patient is often unable to communicate well, who better to explain things to the medical staff and hear from the doctors during their rounds than a family member?

This blog post stimulated lots of comments. One person wrote:

“My mom is an RN who works at a teaching hospital in upstate NY that went to open visiting hours. She works on the MICU and has described this policy as an absolute disaster. The open visiting hours have resulted in entire families coming in at all hours, and the nursing staff now finds themselves taking care of dysfunctional extended families.”

Another nurse wrote:

“One potential problem with allowing all families open visitation 24/7 occasionally poses an issue with some families who do not cooperate with nursing staff, especially when asked to step out of a patients room during nursing interventions to protect the patient’s dignity.”

To these, another person responded:

“The ICU can be a very intimidating place for patients and families. Open visitation policies are a very forward thinking idea that allows health care to shed a little bit of the technical disease-oriented approach by elevating the role of relationships between family, patient and staff….”

“Open visiting hours should be complemented with a policy outlining the responsibilities of the visitors as well to help ensure the best care for their loved one. Any such information should be given in a way that includes the family as part of the team to make the patient better, as opposed to a patronizing tone that may alienate them.”

And my friend Maureen Bisognano from the Institute for Healthcare Improvement replied:

“Though a rare problem may occur, you are right to design the system for the norm, and to ensure that families are welcome, invited and a part of the care team.”

As you can see, these were all thoughtful comments, reflecting a diverse set of experiences even among this small group of folks. So imagine the difficulty of mediating this kind of discussion among the several hundred people who work in our ICUs, caring for about 5,500 patients per year. That gets me to the real point of this column. Changes in clinical care patterns must have the support of those involved in the delivery of care. That support is best gained when the medical staff meets in an environment of mutual respect and exploration. They must have a willingness to experiment. Yes, of course, analysis and review of the literature is important as part of the fact-finding process, but there is a point where the group must feel empowered to make a decision to try out something new. The key is to have that change designed by the medical staff themselves (hopefully with input from patient and family advisory councils). Also, there is a need to measure and monitor results according to mutually agreed upon metrics. Midcourse corrections are inevitable in this situation, so the planning group has to expect to reconvene from time to time to check in and modify plans and procedures.

I have been proud of the efforts made by our ICU staff in this regard. While they are just midway through their system redesign work, I know that they would be willing to share what they have done with care teams at other hospitals. One job of academic medical centers is to expand knowledge — not only of disease and therapies — but of the delivery of care.

If you would like to get in touch with them, please write me at plevy [at] BIDMC [dot] harvard [dot] edu.

-Paul Levy

Doctors Can Learn To Have A Better Bedside Manner

(Originally published on Bedside Manner at Everyday Health)
A recent study showing that compassion can indeed be taught crossed the newswires recently, and boy did it hit a chord. Last I checked, there were 173 comments in response to New York Times reporter Tara Parker-Pope’s post about the study on her blog “Well.”

Admittedly, I didn’t read every single comment, but I read a good chunk of them, and people were all over the map in terms of whether they buy the idea that you can teach someone to be a more humanistic doctor. Readers shared plenty of horror stories as well as examples of warm, engaged doctors who held patients’ hands during difficult moments, sat on the sides of their beds to talk, etc.

I liked what one reader wrote: “Contrary to popular belief, most medical students and doctors do not lack empathy, but are not given the tools to express it appropriately. It takes courage to sit on the side of the bed.”

As several people noted, medical schools have done a much better job in recent years of teaching the humanistic skills of doctoring as well as the technical and medical ones. But I believe that training has to be ongoing. I don’t think you can set young doctors loose on the world, with a little training in compassionate caregiving under their belt and say, “now be compassionate for the rest of your career.”

The study focused on training experienced doctor-teachers to teach and model compassion with their medical students and residents. When compared to a control group, those doctor-teachers were found to be very effective in passing on their skills. As part of their compassion training, they would meet together to reflect on their own work through discussion and writing.

I believe that self-reflection is so very important to creating compassionate caregivers, but how many busy doctors - or nurses- have the time or space for that?

For the past decade some healthcare institutions have been carving out the time and space for that. Currently 165 healthcare facilities across the country - most of them hospitals- now sponsor monthly or bi-monthly sessions called Schwartz Center Rounds. Unlike regular Rounds, where hospital staff talk about a patient case that was interesting or instructive for clinical reasons, these sessions focus on patient cases that were interesting or instructive for psychosocial reasons. The Chinese man who refused a bone marrow transplant because of his religious beliefs about blood, the 89-year-old man who wants to die but whose family continues to press for futile medical interventions or the 30-something patient dying of cancer, whose caregivers are having trouble “letting go” of him because he has been a charismatic presence at the hospital for years are all examples of that.

The idea is that through thoughtful processing of the tough emotions that come up in their daily work, caregivers are better able to relate to their patients on a human level. And according to a rigorous evaluation of the program, it’s working.