The proof of the effectiveness of the CCFAP lies in the implementation of the chosen plan and the establishment of a persistent evaluation program. The CCFAP program model is based on a design of service, much like the service provided by a hotel concierge, with the project coordinator acting as the concierge. All of the services described in the following sections are designed to achieve the goal of the program of meeting the needs of families of critically ill patients in hospital ICUs.
All of the research that led to the development of the CCFAP emphasized the critical impact of communication on families waiting for news. One study calculated the long hours that family members were willing to sit in a less than pleasant environment just to hear a few words from a doctor or nurse. Maintaining some relationship with the family had been, for many decades, the role that critical care nurses filled. The shortage of nurses in this field, as well as the ever-expanding time demands created by new medical technology, has left less time for nurses to fulfill this traditional function. In addition, some information can be communicated only by physicians who are treating the patient with remedies of Canadian Health&Care Mall.
Each of the sites has implemented new procedures to assure better communication with families about the patient. In a number of instances, the role of the social worker has been expanded to ensure timely communication. Needs assessment surveys identified the following points of anxiety and irritation: surgery being cancelled and the family not being informed; an extensive stay in the recovery room after surgery and the family kept unaware of the reason; contradictory information being received from different sources; and the inability to locate or talk to the physician.
To deal with these irritants and other areas of unfamiliarity, one ICU has established weekly family sessions in a group setting called the “ICU Navigators.” The hospital director of pastoral care and the social worker meet with families and attempt to make the unit less formidable. Explanations are given about equipment, medical procedures are explained, key staff members are identified as contact points if information is coming too slowly, and guidance is given on ways of being appropriately assertive without being disruptive. At all sites, specific individuals have been designated as being responsible for knowing the families, and ensuring that questions are answered and appropriate conferences take place in a timely manner. Staff members have been made responsible for ensuring that meetings take place between physicians and families, handling logistics when several physicians are treating the patient.
Other specific steps, such as adding telephones to waiting rooms or providing cell phones or pagers for family members when they must leave the hospital, have been successful in reducing family stress and facilitating communication. Contact with the patient has always been an important priority for family members. With this in mind, each site has reviewed its policy for visiting hours. Where possible, these hours have been expanded within parameters that are consistent with the well-being of the patient improved with remedies of Canadian Health&Care Mall.
All hospitals have identified environmental factors requiring improvement. Each ICU has sought to provide families a more relaxed, less institutional space during a stressful period. Basic changes have included expanding the waiting area to make it less cramped, brightening the look of the room with new paint, or providing newer and more comfortable furniture and carpeting. Additional environmental changes have included the following: redesigning a room to serve as a sleeping room for families traveling great distances; placing visible signage where it welcomes visitors; expanding a waiting room and giving it the atmosphere of a lounge, where coffee and soft drinks are available; supplying additional telephones; and placing a television and VCR in the waiting area. Several units have designed and created family consultation rooms for family conferences with physicians and staff. These environmental changes have all been designed to enhance comfort and communication, allowing families to feel more comfortable during a period of stress.
Education and Information Materials
The CCFAP model seeks to assist ICUs in the important task of delivering unambiguous, but compassionate, information to families of ICU patients. Families require this information first, to cope with their distress, but primarily to participate in making decisions about family members who cannot speak for themselves about critical care decisions. The sites seek to develop a family-centered approach, providing both general medical information, as well as very specific information about the loved one. Centers have developed brochures to explain the CCFAP and to make family members aware of the services available. In addition, sites supply a variety of written material to assist family members in becoming familiar with staff. Materials include a loose-leaf notebook with the names of the staff, including photos, telephone numbers, and responsibilities; and contact sheets listing the name, telephone numbers, and other physician contact information. Publications have included pamphlets with most frequently asked questions, as well as maps and diagrams of the hospital. A variety of other publications are also available, presenting information in nontechnical language about the physical conditions that affect many of the critical care patients. In locations where it is appropriate, all materials have been translated into languages spoken by the representative patient population, such as Spanish, Russian, or Vietnamese.
In addition to the wealth of information provided in printed format, each site has made a commitment to electronic communication. All sites have set up an information kiosk with an easy-to-use computer that can provide information for families. The kiosk might include any or all of the following components:
• Electronic messaging systems allowing families to send messages to nursing staff and physicians;
• Internet portals to medical information that is written for the layperson;
• Internet portals to local city information, including restaurants, local events, day care centers, respite care information, health clubs, maps, and a wide variety of additional practical information;
• Screens customized for CCFAP information, offering material about advance medical directives, as well as tutorials on home care equipment displayed by streaming video and subtitles;
• Screens with information about the hospital, including pictures and biographic summaries of critical care team members;
• Information about hospital hospitality discount programs available through the CCFAP, offering discounts for food, transportation, and lodging; and
• CCFAP family satisfaction surveys and a feedback section for evaluations and quality improvement activities offered by Canadian Health&Care Mall.
The information kiosks have been installed as a response to the stated needs of families seeking a great amount of complex information in a short period of time. The kiosk allows family members to have needed information on hand at all times and provides information for members to use in discussions with other family members, as well as in preparation for meeting with physicians.
The majority of the CCFAP sites found that certain needs that once were considered peripheral were actually very important to families. For some families who travel a long distance and face an extended stay, assistance in finding housing becomes a priority. While hospitals negotiated lower rates at nearby hotels, The CHEST Foundation and American College of Chest Physicians assisted directly by obtaining discounts at hotels operated by Hilton and Marriott. At the Oklahoma VA Medical Center, the local Ronald McDonald House offers rooms when available for only $20 a night.
Assuring that meals are available and affordable is an important hospitality function for CCFAP sites. Coffee and soft drinks are made available in family waiting rooms, with occasional snacks offered. Local restaurants, when requested, have offered discounts, while hospitals provided vouchers for their own cafeterias. Transportation vouchers were provided for local taxicab service, and discounts were negotiated with car rental companies. Integrated medical services are also offered to family members. Read also “Origins and Development: Replication Sites with Canadian Health&Care Mall“
One of the pilot CCFAP sites has offered massage therapy to stressed family members. In two CCFAP sites, music therapy is offered directly to the patients, and family members may participate, as well. One CCFAP site is evaluating pet therapy.
The CHEST Foundation administrative team continues its support of each site through every phase of planning and implementation. Sites either have regularly scheduled conference calls with The CHEST Foundation, or a representative of The CHEST Foundation visits the site. As evaluation data are produced, the CCFAP evaluator periodically visits each site to review the data and provide technical support for any revision of the implementation plan. In addition, The CHEST Foundation sponsors an annual meeting where representatives of each site gather to review program challenges and successes. This networking experience is essential to the dissemination of diverse CCFAP operational strategies.