Penn studies including families in ICU medical rounds

Unlike at many hospitals, the medical team at Hospital of the University of Pennsylvania's surgical intensive care unit has embraced the idea of including families in physician rounds.

That helps families form realistic expectations and helps the staff get to know patients who are often too sick to talk, said Daniel Holena, a Penn surgeon who specializes in critical care, trauma, and emergency surgery.

But distance and work responsibilities can make it difficult for some family members to be physically in the hospital when teams discuss patients.

A Penn study published last week in the American Journal of Critical Care examined what family members and providers considered the pluses and minuses of inclusive rounds. It also found that both groups were receptive to trying telemedicine, which is now widely used in many types of medical care. But in a later test, current technology was too hard for some family members.

"We got some very positive feedback," said Holena, a study co-author. "There were also some logistical barriers that I'm not quite sure we have a handle on yet."

Not that long ago, ICUs typically limited when and how long family members could visit, so that patients could rest and exposure to outside germs was reduced. Most still do, although rules are loosening. Penn now has an open-door policy for family visitation in its surgical ICU, Holena said. Family members can even sleep in the room if they want. The staff also invites family members who are visiting to listen in on rounds and ask questions.

Holena said the medical team on his 24-bed unit rounds three times a day. In the morning, attending physicians, residents, nurses, fellows, medical students, pharmacists and respiratory therapists go from room to room discussing how patients are doing and plotting their plan of care for the day. Smaller teams round late in the afternoon and early in the evening.

On any given day, Holena estimates that 30 to 50 percent of patients have family visiting during rounds.

"A lot of what we do is guided by what the family can tell us about what the patient would want in a given situation," he said.

The rounds also help families better understand how a patient is doing. ICU patients are often so sick that families are faced with tough, end-of-life decisions. "It gives them a chance to sort of have their expectations meet what we see for the patient," Holena said. Family members have told him that staff facial expressions and body language help them know where things are heading. "I can tell by the way things went in rounds this morning," they'll say, "that last night wasn't a good night."

In interviews with 32 family and staff members, the research team also found some problems.

The medical professionals worried that including families would make rounds, which already take about three hours in the morning, even longer. Unless they've spent a lot of time around doctors, family members need simpler language than staff members use among themselves. The doctors end up saying things once in medicalese and again in lay terms, Holena said.

There was also concern from the staff about what they could say in front of the family, since some of the information they discuss is upsetting. Holena said the team is open with families, but chooses words carefully. "If the family's not present, we may use more blunt language in describing the expected course," he said.

Family members, meanwhile, were worried about slowing things down and had trouble understanding the medical jargon. Because rounds do not occur at set times for specific patients, it was also often hard for family members to be there at the right time.

That's what prompted the exploration of telemedicine.

After they completed the research, the surgical ICU team tried using VSee, a FaceTime-like program often used in medical settings. They rounded with a computer tablet mounted on a pole with wheels. Family members were also given a tablet.

However, the team soon learned that age was a problem. Many of their patients were elderly people with elderly spouses. Even requiring a password - the hospital had to meet medical privacy rules - was too big a barrier for many of the older family members.

Younger relatives were more enthused. One man liked telemedicine so much that he used it even when he was in the hospital, Holena said.

He is hopeful that telemedicine will be an option when technology gets easier to use. "It did give us a ray of hope," he said, "that this is something that families are going to be able to use in the future."

He conceded, though, that rounds are only one way, and not necessarily the best one, for families to stay in the loop. Many times, it's still better for doctors to sit down with families and talk.

"Sometimes people will circle back after rounds and tend to have a more dedicated, one-on-one conversation," said. "That's what I do."

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