Cappellini, Elena RN; Bambi, Stefano MSN, RN; Lucchini, Alberto RN; Milanesio, Erika MSN, RN
Intensive care units (ICUs) were established less than 50 years ago. Over time, ICUs have undergone several changes due to technological progress and new scientific discoveries.1 In some settings, patients and their relatives view ICUs as closed environments, almost completely inaccessible.
Giannini et al2 used the metaphor of “revolving door” to explain the concept behind ICUs’ visiting policy until a few years ago. The “revolving door” was the mechanism that left out the relatives when the patients were entering the ICU.2
Patients in ICUs suffer physical and psychological stress conditions that have repercussions on the entire family.3 At the time of admission in critical care units, most patients feel anxiety, depression, isolation, and loneliness, which can go on for a long time even after discharge.4 For this reason, the presence of relatives during patients’ stay in ICUs is considered very important. A North American study about the causes of suffering for patients in ICUs found that limitations to the visits by relatives were a major reason for distress.5
Even though liberalization of visiting hours exists, this issue has been debated in literature since 1984. Open visiting policies in ICUs are well described in literature from the second half of the 1990s.6-9 However, the widespread diffusion of the “open ICUs” concept has taken place only during the last decade, with the introduction of guidelines dedicated to the support of relatives in ICU, and with the trend toward a more humane and personal approach to patient care.10,11
The concept underlying “open ICUs” consists in a vision of a “ward where one of the aims of the medical team is a rational reduction or abolition of temporal, physical, and relational restrictions.”12 The temporal dimension is represented by the liberalization of visiting policies, including the removal of narrow time limits, which historically did not exceed 60 minutes on a single day.12 Moreover, the liberalization of visiting policies supports a larger presence of relatives at the patients’ bedsides.
Physical dimension is the overcoming many of the imposed barriers to physical contact between relatives and patients. These include the expressed prohibition to touch the patient, and the so-called “dressing procedures” or precautions (gowns, gloves, overshoes, and caps), even when these are not necessary.13
Finally, the relational dimension is represented by a climate of trust between the ICU staff and the relatives, extending beyond the professional duty of providing clinical information about the patient.14
The underlying rationale is that relatives represent an essential part of the health of each person and are key components of many dimensions related to healing. Key concepts as “opening of ICUs,” “flexibility,” and “case-by-case basis evaluation” are contained in the clinical practice guidelines for support of relatives in the patient-centered ICU by the American College of Critical Care Medicine.10 These recommendations constitute a solid basis of ethics for the implementation of open ICU programs.10
The traditional “closed ICU” restricts the visiting hours and prevents the relatives’ access to the patient, limiting both physical and emotional support. The major factors limiting the expansion of open ICUs as healthy environments for patients and relatives are visiting policies and the beliefs of health care staff.
We reviewed the nursing and medical literature to describe the current status of liberalization of visiting hours policies in ICUs. Moreover, we explored the impact of open ICUs on the perception of patients, visitors, and staff. Finally, we have evaluated the impact of open ICUs’ influence on patients’ outcome.
MATERIALS AND METHODS
We searched original research papers and conference proceedings published from January 1, 2002, to December 31, 2011, on MEDLINE, EMBASE, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. The time limits were setting to the last 10 years to emphasize the research results open ICUs coming from the period of their international widespread. Limits of research were set on adult population and English or Italian language. Keywords and searching criteria are summarized in Table 1. Exclusion criteria from our review were articles that consisted solely of narrative review, editorial, letter, and comment articles.
We examined the references lists of included articles and retrieved articles if relevant for this review, even when published before 2002. Flowchart of articles selection is represented in the Figure. After the screening of the retrieved articles, we selected and included 20 articles for this review. In addition, we retrieved and added 9 articles through the consultation of articles’ references, for a total of 29 articles.
Figure. Flow chart o...Image Tools
The results of selected studies are summarized in Table 2.
DIFFUSION OF OPEN INTENSIVE CARE UNITS
The opening of ICUs to relatives continues to generate challenges as shown by the lack of ICUs with liberalized visiting hours policies.3,15 Sweden has 70% of open ICUs, whereas in the United States, the percentage drops to 32%, in France to 23%, and in United Kingdom to 20%.16-19 In Belgium and in Italy, ICUs are almost all “closed,” that is, with restricted visiting policies.1 Giannini et al,2 in a national survey performed in 2007 on 303 Italian ICUs, showed that 99% had an average visiting time of 1 hour per day. However, at the time of this study, one-third of ICUs were “rethinking their policies of access.”2 In fact, another study published during the same year, performed in the northeastern regions of Italy, showed that 14% of ICUs endorsed liberalized visiting hours policies.20
The traditional visiting hours policies recorded in literature are quite variable, ranging from the total interdiction to access, up to 240 minutes of relatives’ visiting time per day.2,21 However, there are varied interpretations for the term “open ICU,” ranging from situations in which visiting hours are confined to precise segments, to a few ICUs allowing unrestricted access 24 hours per day.2,3,21-25 Most of the visits are allowed during the afternoon. This is usually the interval of time preferred by visitors, especially from 2:00 PM to 8:00 PM, even in the ICUs open 24 hours per day.25 A large part of the medical staff (80%) expressed hope to see a greater flexibility in the visiting hours.3 Some ICU teams make exceptions to the visiting policies in special cases, such as dying patients, contingent needs of relatives, or particular emotive/psychological conditions.1,2,15,20
Regardless the visiting hours policies, almost all ICUs tend to not admit more than 2 visitors per patient. In 17% of the Italian ICUs surveyed by Giannini et al,2 access is allowed only to the closest relatives.
Articles reporting the access of children as visitors in ICUs revealed the presence of very different rules. Children 12 years or younger are not allowed to enter in 91% of ICUs in the United States, and in 78% in northeast of Italy.17,20 There is also a total ban on access for children of any age in 69% of Italian ICUs, in 11% of French ICUs, and in 9% of Flemish ICUs.1-3
Another singular feature of critical care units’ visiting hours policies is the obligation to wear protective clothing. The dressing procedures for ICU visitors vary on the basis of the setting studied. Italy is the nation with the higher imposition of protective clothing for relatives.2 Wearing gowns is reported in many ICUs, with percentages ranging from 23% in United Kingdom to 91% in Italy.2,19 Even the overshoe covers are widely used in ICUs up to 87%, whereas wearing caps ranges from 2% to 51%, and similarly, surgical masks (1%-47%).2,3 However, wearing gloves as protective clothing is less imposed on visitors (1%-12%).2,3 However, the usefulness of protective clothes worn by relatives is not demonstrated. More studies are needed to support this practice for the prevention of multiresistant organism transmission.26 Hand washing and the application of standard precautions for patients at risk of infections’ transmission still remain mandatory.26
THE PATIENTS’ PERSPECTIVE
In a US study, patients identified a preference to receiving relative visits in afternoon hours (50%) and to end the visits within 8 pm (32%).27 Patients state that the presence of relatives provide them with emotive support and can help them to better understand the information given by the staff. In addition, relatives are a source of important information about the medical history and the needs of patients.27
In 63 patients admitted to the cardiac ICU and 61 patients in high-dependency unit, 49% of the cardiac ICU patients and 64% of high-dependency unit patients preferred visiting hours policies without restrictions of time, duration, and number of visitors.28 A descriptive study by Azzi and Bambi23 showed that 91% of patients were favorable to the presence of relatives in ICU without time limits.
Another Italian study performed in 1 ICU explored the patients’ perception of quality of care before and after the introduction of an open visiting hours policy.29 During the period of restricted visiting hours, the main factors of patient discomfort were pain, endotracheal tube placement, and the inability to move. Those recorded during the open visiting hours policy were instead noise, fear, disturbed sleep, and medical visits.29 The relief factors most reported in the period before opening the ICU were the “constant presence of health care workers,” followed by “their competence” and “cleaning/personal hygiene.”29 After the liberalization of visiting hours, patients indicated relief factors as the “presence of relatives” and the “ability to relieve pain.” Furthermore, patients with open visiting hours policy conveyed a more positive evaluation of ICU stay.29
THE FAMILY’S PERSPECTIVE
Relatives’ dissatisfaction is often related to the lack of information (22%), entering alone in the ICU (25%), and receiving information in a room not suitable (23%).4,30
The need to be informed and reassured was the most frequently reported family need from a survey conducted in 2000 using the Critical Care Family Needs Inventory in a Belgian ICU. The aim of the study was to investigate the needs of the relatives of patients admitted in ICU, as well as the perspective of medical and nursing staff.31 The study also found that the needs of relatives are generally underestimated by the health care professionals.31
In Italy, Azzi and Bambi23 have used the same Critical Care Family Needs Inventory for the families of patients staying in 2 “open” ICUs and in 2 ICUs with restricted visiting policies. In their study, 90% of relatives were in favor of less restrictive visiting hours. Open visiting policies provided the satisfaction of needs such as “to see the patient more frequently” (96%), “to be sure that the patient is comfortable” (92%), “to obtain information from doctors or nurses at least 1 time a day” (85%), and “to pass more time with their loved one” (81%).23 The analysis of data showed that overall 90% of relatives were satisfied with the responses received to their needs, but with a higher percentage of “completely satisfied” reported by open visiting policy group.23
In a research published in 2005, health care personnel of 78 French ICUs have given the opportunity to care for patients to 544 relatives, but only 33% of them agreed to.32 Of this group, 84% agreed because of their desire to support the patient and 58% to help the staff in ICU. Those who have decided to not take part in the care of patients added the motivation to decline was because they determined that work appeared to be done properly by the ICU staff (85%).32
Another issue is the relatives’ participation in patient care. Garrouste-Orgeas et al33 surveyed the perception of staff and relatives assisting or taking part to nursing activities on 129 patients in a medical-surgical ICU. They found that 97% of families were in favor of participating to almost all of 13 basic nursing activities. In follow-up interviews, 72% of patients agreed with relative participation.33
Patient stay in the ICU causes anxiety and depression in relatives.4 In 544 relatives surveyed about these disorders, 73% suffered from anxiety, and 35% from depression.32 In another study, 8% of relatives reported receiving support from a psychologist after family member admission to the ICU, and the same percentage had taken psychotropic medications prescribed by a physician after the ICU stay of their loved one.4 In addition, 1 in 3 relatives is at risk of developing posttraumatic stress disorder, with a few days of a family member’s ICU admission.4
THE INTENSIVE CARE UNIT MEDICAL AND NURSING STAFF’S PERSPECTIVE
In 2003, Azoulay and colleagues32 found that a high percentage of ICU staff members (88%) considered it desirable to involve relatives in patient care, with careful education from health care personnel (74%) or in presence of the staff (67%). The positive attitude of the French professionals was confirmed by another study, conducted in 2010 on 731 staff members from 263 ICUs.34 In this study, 63% of those who work with a restricted visiting policy consider it useful to extend visiting hours, whereas only 9% of those employed in an open ICU would prefer a reduction.34
Conversely, most of Belgian nurses in 2007 expressed opposition to the opening of their ICUs (75%).They believed that open visiting policies could not be helpful for the patients’ stay in ICUs (56%), nor would it offer comfort (58%).15 Also almost all (94%) the Athenian nurses from 6 ICUs are opposed to open visiting policies; 85% stated this was because they do not recognize relatives as a support for the patient.35
In Italy, about 60% of the medical and nursing staff involved in a survey of 28 ICUs of the Tuscany region recognized the value and benefits of an open visiting policy for patients and their families. Conversely, they highlighted architectural and organizational problems that an open visiting policy may present. Moreover, the authors found the needs of personnel included improving communication skills and receiving further information on the open ICU implementation models.36
Overall, the studies included in this review reflect possible beneficial effects of open ICUs for patients and families; however, others emphasize important fears about the potential interferences of relatives with the planning and the care of patients.15,35,36 In addition, ICU teams report increased workloads associated with family presence due to the continuous demands for information.15,35,36
The literature does not report data about the increase in clinical errors, delays in activities, or increased complexity of care in the presence of relatives. A study carried out in 2009 in 3 Italian ICUs showed that open visiting policies are believed to promote the physical and psychological recovery of the patients. This is more common among the team of open ICUs than in closed ICUs (91% vs 63% for doctors, 84 % vs 67% for nurses).19,23 Similarly, these studies support the opinion that open ICUs can help to reduce the anxiety of relatives (73% vs 60% for doctors, 73% vs 67% for nurses).23
Nurses working in a Spanish ICU expressed positive opinions, in addition to the benefits already discussed.35 In addition, others pointed out that relatives can provide emotional support to their loved ones and help to make the ICU stay less boring.37 However, these positive effects depend on the conditions of patient and his/her relatives, as well as on the relatives’ ability to handle stress and comfort the patient.37,38 Relatives are recognized as a valuable source of information about the patients but, at the same time, can cause interruptions in care.23,37
According to Roch et al,34 the belief that open visiting policies interfere with health care is more prevalent among those who work in open ICUs (46% vs 8%), as well as the opinion that improves the relationship with the families of patients (81% vs 35%). Azzi and Bambi23 also showed how doctors of “open” and “closed” ICU agree in stating that a liberalization of visiting policy negatively affected the whole team (respectively, 46% and 54%). Similarly, 45% of nurses employed in “open” ICUs and 55% of those in “closed” ICU think that open visiting policies are obstacles to the plan of care designed for patients and make an impression that the team is under surveillance.23
Differences of opinion arise among physicians and nurses. Garrouste-Orgeas and colleagues25 administered a questionnaire to 13 doctors and 30 nurses working in a medical-surgical ICU with open visiting hours 24 hours per day. Nurses reported the impression of greater disorganization when compared with doctors (P = .008) and a lower perception of the expression of trust in the ICU staff by relatives (P = .0023).25 Doctors were less at ease than nurses during the examination of patients (P = .02).25
Doctors had a more favorable opinion than did nurses about the extended duration of visits, (odds ratio, 0.35; P < .001), even several months after changes in visiting time were made (odds ratio, 0.5; P < .001).39
A recent pre-post study conducted in Italy on 8 ICUs showed in both periods of study a statistically significant nurses, regarding opening visiting policies (P = .032 and P = .005).40 However, doctors and nurses agree on the willingness to change visiting hours in the presence of dying patients and patients with psychological and emotional problems or special needs of relatives, although avoiding overnight stays.1,23,30,38
Finally, nurses have indicated potential difficulties associated with the presence of relatives due to structural and architectural features of the ICU.30 This is probably due to the lack of space to accommodate relatives when they are not at the patient’s bedside or when providing information.30 The absence of private cubicles or curtains preserving the privacy of patients during nursing and medical care is perceived as an obstacle to open ICU implementation.30
In summary, studies comparing the perceptions of health care professionals employed in open ICUs and in ICUs with restricted visiting policies help to better delineate the possible advantages and disadvantages of the opening visiting policies. This research highlights similarities and differences of opinions between various settings and between doctors and nurses across many countries. The perception of nurses toward the issue of open ICUs remains veiled by doubts and challenges, affecting attitudes and positive opinions about the potential effects of open ICUs on patients and families.23,30 However, benefits for patients, as well as for the teams and the medical and nursing care, are confirmed.23,37
INFLUENCE OF OPEN VISITING POLICIES ON PATIENT OUTCOMES
Patients admitted to the ICU have a high risk of infective complications because of recurrent exposure to invasive procedures and decreased immunity. The results of this prevalence is reported in an EPIC II study, which showed of 14 414 patients from 1265 ICUs, 51% of patients developed an infection.41
In this literature search, there are no studies reporting about the influence of open ICU programs on patients’ major outcomes such as ICU or hospital mortality and length of stay, except for the risk of infection induced by the visitors. However, even this topic has very limited data.
The only randomized clinical trial on the effect of open ICU visiting policy on patient outcome was conducted by Fumagalli and colleagues24 in 2006 in a cardiac ICU on 226 cardiac patients. This sample was divided into 2 groups based on the visiting hours policy. Groups were divided into restricted or enhanced visiting hours. The authors’ findings showed that the adoption of an open visiting hours policy determined a higher environmental bacterial contamination.24 However, there were no statistically significant differences in septic complications, urinary tract infections, and pneumonia between the 2 groups of patients, even after adjusting for gender, age, and period of enrollment.24 In contrast, the risk of any type of cardiovascular complication, such as major cardiac arrhythmias, cardiac rupture, and acute cardiac failure, doubled in the group with restricted visiting hours policy (P = .03).24 Moreover, patients’ hospital mortality in the open visiting hours group was 2% versus 5% in the restricted visiting policy group, but without statistical significance (P = .28).24 Finally, the scores on the Hospital Anxiety and Depression Scale measured on the patients at the moment of discharge were better in the open visiting policy group.24
A pre-post study published by Malacarne et al22 in 2011 compared the incidence of ICU infections over 2 periods with different visiting hours policies. In the first phase, only 2 relatives were admitted for an hour per day. In the second phase, 4 visitors were admitted for 3 hours per day. The authors did not find any statistically significant differences in incidence and types of patients’ infections between the 2 periods.22 The same author, in 2008, had already shown that the swabs of hands’ skin and nasal mucosa of visitors during opening visiting hours policy were negative for microorganisms that caused infection in ICU patients.42 In this study, visitors were obliged only to wear a hospital gown and to observe hand hygiene before entering and leaving the ICU.42
The results of this literature review justify the need to change the definition of open ICU provided by Giannini et al,2 replacing the term “medical team” with “multiprofessional team of ICU.”12 In fact, all the members of ICU staff contribute to caring for visitors and meeting their needs. However, various elements of discussion emerged from the literature analysis that are predominantly descriptive, indicating the need for advanced research study.
First, there is not a universal interpretation for the concept of visiting policies liberalization, because there is a great variability for the “open” visiting hours and for the number of visitors among countries (and between ICUs in the same country). It should be a desirable goal to extend ICU policies to allow opening visiting hours to 24 hours per day.
Second, thinking that the wide range of diffusion of open ICU among countries relies on the beliefs of staff could be too simplistic. There are, instead, some variables often not well explored by studies, such as the physical design of ICUs. An open space ICU is probably less adequate to host visitors at the patient’s bedside than a single cubicle unit. Perhaps, it is a problem not only of preserving patients’ privacy, but also that which the health care staff needs to consider as they must move safely around the patients, and the use of curtains seems to be restrictive.
In light of the nurses’ conflicting opinions about open ICUs, nursing research should be performed to explore 2 major topics: nursing workload measurement when relatives are inside ICUs and the nurses’ self-perception of confidence and ability to accomplish their duty under “strangers’ eyes.”
The opinion of the nursing assistants about open ICU is still scarcely studied. In some hospitals, they are an important interface between nurses and patients and their relatives, because part of the basic care can be delegated to them, determining a remarkable communication load. Ignoring the contribution of these professionals in relation to the success of open ICU programs could be a mistake.
More observational studies should be performed to give a definitive answer to the real needs of protective clothes for visitors in ICUs. We actually cannot afford the costs of tens of single-use gowns, overshoes, caps, and gloves, in absence of strong evidence of necessity or focused indications (eg, multiresistant organisms).
Relatives must be attentive and carefully assessed by the ICU staff for the needs of information, participation in patient’s care, and for subtle symptoms of mental discomfort, because they can be at risk of developing posttraumatic stress disorder.
Moreover, there is the need to clarify the reasons why children could not be freely allowed to enter in ICUs: is it a problem related to their physical safety (eg, risk of infection) or a psychological issue that may indicate they should be restricted? The wide variability of rules related to children’s access in international published researches seems to indicate that it is mainly a cultural problem.
The influence of open ICU programs on patients’ mental and physical outcomes remains a big challenge, because there is a lack of studies in literature. For example, we at present do not know if the continuous presence of relatives at the bedside can reduce the incidence of delirium or influence vital signs such as respiratory or cardiac rate, consequently affecting the oxygen consumption of critical care patients. Although we must consider many variables, we cannot rely on any one outcome to decide to implement liberalization of visiting policies. It mainly remains an ethical priority and must be designed to meet the overall needs of the patient.
An important milestone emerged from this literature review, which indicates that all research involving relatives showed that families want to stay at the bedside of their loved ones in ICUs. Why do not give them this opportunity? Therefore, the definitive implementation of ICUs’ programs could probably find an answer in “ad hoc” legislation. If family- and patient-centered care is a high ethical target for the health care systems, adequate policies to support the liberalization of visiting hours can be a key intervention to accomplish this goal.
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