Using the FS-ICU Instrument: Understanding and Improving

Family Satisfaction in a Neuro ICU

David Y. Hwang, MDAssistant Professor of Neurology

Division of Neurocritical Care and Emergency Neurology Yale School of Medicine

Jennifer Robinson, APRNYale-New Haven Hospital

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Lori Harmon, RRT, MBADirector, Program DevelopmentSociety of Critical Care MedicineMount Prospect, IL

Today’s webcast is supported by grant number R18HS021940 from the Agency for Healthcare Research and Quality. The content is solely The responsibility of the presenters and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

David Hwang, MDAssistant Professor of Neurology Division of Neurocritical Care and Emergency Neurology Yale School of Medicine

Jennifer Robinson, APRNNeuroscience ICUYale-New Haven HospitalAdjunct FacultyYale University

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Using the FS-ICU instrument:Understanding and improving family satisfaction in a Neuro

ICU

SCCM Project Dispatch Webcast 02/05/2014David Y. Hwang, MDAssistant Professor of NeurologyYale Division of Neurocritical Care and Emergency Neurology

Jennifer Robinson, APRNYale Neuroscience

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Disclosures

• David Y. Hwang, MD– American Brain Foundation Practice Research Training

Fellowship– Remedy Pharmaceuticals, Inc. (GAMES-RP clinical trial site

PI)– Bayer HealthCare (legal consulting)– Oxford University Press (book)

• Jennifer Robinson, APRN– None

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ngm.nationalgeographic.com

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www.grassrootsmusic.org

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Outline

• Importance of research on ICU family experiences

• Available survey tools for assessing family satisfaction– Focus on FS-ICU

• Multidisciplinary team approach at Yale for collecting survey data

• Details of data collection setup, including troubleshooting problems

• Recent survey results from Yale-New Haven Hospital Neuro ICU

• Possible future directions

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Importance of research on ICU family experiences

• Institute of Medicine 2001 report

– Recommendation for healthcare delivery to be “patient-centered”

– Shared decision making

– Coordinated care

– Physical/emotional support

– Culturally competentIOM. National Academies Press 2001

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Importance of research on ICU family experiences

Crit Care Med 2007;35:605

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Importance of research on ICU family experiences

• As of October 2012, the Affordable Care Act ties consumer satisfaction to hospital reimbursement

• Medicare withholds 1% of normal reimbursement for a “bonus fund”

• Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey– Assesses patients’

perception of care– Scores factored into

bonuses

www.washingtonpost.com/blogs/wonkblog

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Importance of research on ICU family experiences

• Does family satisfaction with ICU care correlate with long-term family outcomes?

– Caregiver burden for survivors

– Grief and bereavement for nonsurvivors

– Postintensive care syndrome (PICS-F)• Anxiety• Depression• PTSD• Acute Stress Disorder

Rothen et al. Curr Opin Crit Care 2010;16:623

Davidson et al. Crit Care Med 2012;40(2):618

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Importance of research on ICU family experiences

• Despite existing controversies and uncertain influence of family satisfaction on long-term patient and family outcomes:

– Satisfaction with medical care has become an important quality metric;

– Surveys such as HCAHPS typically capture satisfaction data from patients themselves over the course of an entire hospital stay;

– Quality improvement in ICUs should ideally be guided by ICU-specific information;

– ICU family satisfaction research has thus received increasing attention over the past decade.

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Rothen et al. Curr Opin Crit Care 2010;16:623

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Available survey tools for assessing family satisfaction

• Critical Care Family Needs Inventory (CCFNI)

• Critical Care Family Satisfaction Survey (CCFSS)

• Family Satisfaction in the ICU (FS-ICU)

– FS-ICU 34

– FS-ICU 24

Kentish-Barnes et al. Crit Care Med 2009;37(10):S448

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Johnson et al. Crit Care Med 1998;26:266

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Wasser et al. Crit Care Med 2001;29:192

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FS-ICU

• Initially designed as a 34-item survey

• Half of items address satisfaction with overall care

• Half of items address satisfaction with the shared decision making process

• Survey refined and revalidated in 2007 as a 24-item version

Heyland et al. J Crit Care 2001;16(4):142

Heyland et al. Crit Care Med 2002;30:1413

Wall et al. Crit Care Med 2007;35:271

www.thecarenet.ca

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FS-ICU

• Available for free on the Internet

• Items are mostly scored on a 5-point Likert scale

• Each item can be scored out of 100 points

• Some overlap with patient HCAHPS questions

• Wide use in the literature– Multiple large observational cohorts– Used as outcome instrument for intervention studies

Heyland et al. J Crit Care 2001;16(4):142

Heyland et al. Crit Care Med 2002;30:1413

Wall et al. Crit Care Med 2007;35:271

www.thecarenet.ca

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FS-ICU

FS-ICU 24 items regarding general ICU care

Concern and caring of patient by members of ICU staff

Management of pain

Management of breathlessness

Management of agitation

Coordination of care

Competence of nurses

Competence of physicians

Amount of health care received in ICU

Interest in needs of family

Emotional support for family

Concern and caring of family members by members of ICU staff (courtesy, respect, compassion)

Frequency of communication with ICU nurses with family

Atmosphere in the ICU

Atmosphere in the waiting room

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FS-ICU

FS-ICU 24 items regarding shared decision making

Frequency of communication by ICU doctors

Ease of getting information

Understanding of information

Honesty of information

Completeness of information

Consistency of information

Inclusion in decision making

Support during decision making

Control over the care

Time to address concerns and questions when making decisions

• 3 items for family members whose relatives died during ICU stay: Length of unnecessary prolongation of life Comfort Support by care team during family member’s death

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FS-ICU

• Recent ICU interventional trial using the FS-ICU as outcome instrument

• Qualitative analysis of write-in comments performed• Recurring topics

– Timeliness of information received– Appropriateness of communication in the patient care area– Comportment (professional vs. rude communication)

Shaw, Davidson et al. Crit Care Med 2014;42(2):265

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Yale multidisciplinary team

• Approval by local IRB• Multidisciplinary approach vital to success

– Recruitment of diverse group– Low turnover of team– Core group of 5 members recruiting families– Led by physician and NP– Nursing leadership

• CNS• ICU nurse manager

– Physician assistant– Staff RNs– PA student– Unit business associate / secretary

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Nuts & bolts of data collection

• Monthly reminders to group to sign up for “call schedule” (M-F)• Recorded in group Google calendar account

• “On-call” responsibilities: – Patient selection– Enrollment– Data collection

• Timeline– Window for recruitment 24 hours prior and 8 hours after

discharge from ICU• Family member selection• Exclusion Criteria

– Admission <72 hours, unless made comfort measures– Non English speaking

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Nuts & bolts of data collection

• Survey converted from paper to Google survey• Only de-identified information online• Family and patient demographics stored separately

• Automatically inputs results into Excel spreadsheet• Expired patients collected separately

– Mailed letter detailing research study and paper version of survey

– ~1 month passed before contact• Additional patient demographics of interest collected

– Attending of record– Code status– Insurance– Education of family member– Diagnosis

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Challenges

• Workflow– Time consuming– Harder once patient transferred out of ICU

• Resources– No dedicated research assistant– Not funded

• Technical Issues• Family Response

– ~55% response rate for survivors– Interest

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Benefits

• Fostering teamwork• Involvement of bedside nurses in varied aspects of

research• Exploring our own strengths and weaknesses

– Waiting room• Feedback from families

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Neurocritical Care Society 2013 conference abstract

• Satisfaction with Emotional Support Provided in a Neuroscience Intensive Care Unit Among Families of Surviving Patients with a Neurosurgeon Versus Neurointensivist as the Attending of Record

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NCS abstract chart 1: Most common diagnoses

Neurology Neurosurgery

Intracerebral hemorrhage (37.8%)

Subarachnoid hemorrhage (50%)

Ischemic stroke (24.3%) Traumatic brain injury (10%)

Seizure (24.3%) Subdural hematoma (10%)

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NCS abstract chart 2: Patient demographics

Primary

Service

Age inyearsP=0.009

(SD)

Length of Stay indaysP=0.0001

(SD)

Privately Insured in %p=0.004

(95% CI)

Medicaid Insuredin %p=0.03

(95% CI)

Neurology 69 (14.7) 6.4 (4.4) 54.1 (±16.06) 10.8 (±10)

Neurosurgery 57.2 (12.8) 13.4 (8.9) 40 (±17.53) 33.3 (±16.86)

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NCS abstract figure: Emotional support

• Families reporting complete satisfaction with emotional support

• p = 0.04

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NCS abstract: Conclusions

• In our NICU, neurosurgery families are more likely to be completely satisfied with the emotional support received from staff compared to neurology families.

• Questions:

– Does a longer average length of stay allow NICU staff to build more of a relationship with neurosurgery families?

– Do families feel more support with dual teams & attendings (NICU and neurosurgery) following?

– Do neurosurgery families feel more support with a neurosurgery attending who does not change weekly (vs. rotating intensivists)?

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Influence of year-round neurointensivist coverage

p=0.0505

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Influence of year-round neurointensivist coverage

p=0.0568

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Families with prior ICU experience vs. new to ICU

Survey Variable Prior Exp

None

Frequency of communication by ICU doctors 65.0 69.2

Ease of getting information 82.9 84.6

Understanding of information 75.6 76.9

Honesty of information 82.5 80.8

Completeness of information 75.6 76.9

Consistency of information 65.9 65.4

Inclusion in decision making 70.7 61.5

Support during decision making 53.7 52.0

Control over the care 58.5 54.2

Time to address concerns and questions when making decisions

94.4 92.0

Hwang DY, Robinson J, et al. Crit Care Med 2013;41(12):S830

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Possible future directions

• Advantages of having ongoing ICU family satisfaction data collection:

– Improved understanding of our local Neuro ICU at Yale• Can help target ICU resources for quality improvement

– Approval by Institutional Review Board allows for ongoing analysis and publication/presentation of observational data

– Built-in pre- and post-assessments for any future interventions or change in practice that the team wishes to pursue

– Available pilot data for future grant applications

– Multidisciplinary ICU team building

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Possible future directions

• Future analysis may focus more on surveys from families of those patients who have been made comfort measures only in the Neuro ICU

– Of note, prior analyses have suggested that families of patients who pass away during ICU admission tend to report higher satisfaction than those of patient patients who survive to discharge

• We welcome collaboration with other ICUs collecting FS-ICU data

– Increased observational power with larger number of surveys

– Please e-mail us!

Wall et al. Chest 2007;132:1425

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Our team leaders at Yale

• Kelly Poskus, MS, RN• Cindy Bautista, PhD, RN• Jessica White, PA-C• Meghan McAnaney, RN• Anna Coppola, RN• Maria Koursaris, RN• Nathaniel Anderson, PA student• Lavenita Smith, BA• Kevin Sheth, MD, FCCM, FAHA• Emily Gilmore, MD• David Greer, MD, MA, FCCM, FAHA, FNCS• Evie Marcolini, MD

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Thank you!

David Hwang, MDdavid.hwang@yale.edu

Jennifer Robinson, APRNjennifer.robinson@yale.edu