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Objective It was hypothesized that adding dedicated afternoon rounds for patients' families to supplement standard family support would improve overall family satisfaction with care in a neuroscience ICU. Design Pre- and postimplementation (pre-I and post-I) design. Setting Single academic neuroscience ICU. Patients Patients in the neuroscience ICU admitted for longer than 72 hours or made comfort measures only at any point during neuroscience ICU admission. Intervention The on-service attending intensivist and a neuroscience ICU nursing leader made bedside visits to families to address concerns during regularly scheduled, advertised times two afternoons each week. Measurements and main results One family member per patient during the pre-I and post-I periods was recruited to complete the Family Satisfaction in the ICU 24 instrument. Post-I respondents indicated whether they had participated in the afternoon rounds. For primary outcome, the mean pre-I and post-I composite Family Satisfaction in the ICU 24 scores (on a 100-point scale) were compared. A total of 146 pre-I (March 2013 to October 2014; capture rate, 51.6%) and 141 post-I surveys (October 2014 to December 2015; 47.2%) were collected. There was no difference in mean Family Satisfaction in the ICU 24 score between groups (pre-I, 89.2 ± 11.2; post-I, 87.4 ± 14.2; p = 0.6). In a secondary analysis, there was also no difference in mean Family Satisfaction in the ICU 24 score between the pre-I respondents and the 39.0% of post-I respondents who participated in family rounds. The mean Family Satisfaction in the ICU 24 score of the post-I respondents who reported no participation trended lower than the mean pre-I score, with fewer respondents in this group reporting complete satisfaction with emotional support (75% vs. 54%; p = 0.002), coordination of care (82% vs. 68%; p = 0.03), and frequency of communication by physicians (60% vs. 43%; p = 0.03). Conclusions Dedicated afternoon rounds for families twice a week may not necessarily improve an ICU's overall family satisfaction. Increased dissatisfaction among families who do not or cannot participate is possible.

The quality of family-clinician communication in the intensive care unit is often inadequate, but little is known about specific clinician communication behaviors that might improve family satisfaction. In this exploratory analysis, we hypothesized that clinicians' communication behaviors providing emotional support to families during intensive care unit conferences would be associated with increased family satisfaction.We audiotaped 51 intensive care unit family conferences in which withholding or withdrawing life support was discussed or bad news was delivered. Emotional support techniques used by clinicians during each conference were identified and coded using grounded theory.Four Seattle hospitals.Family members of critically ill patients.Questionnaires rating satisfaction with communication were completed by 169 family members.Linear regression with generalized estimating equation methods was used to analyze the association between the frequency of clinicians' emotionally supportive statements and family satisfaction. Increasing frequency of three types of clinicians' statements during family conferences was associated with increased family satisfaction: a) assurances that the patient will not be abandoned before death (p=.015); b) assurances that the patient will be comfortable and will not suffer (p=.029); and c) support for family's decisions about end- of-life care, including support for family's decision to withdraw or not to withdraw life-support (p=.005).Most family members participating in this study were quite satisfied with the communication in the family conferences. Specific clinician communication behaviors are associated with increased family satisfaction during family conferences among family members who are willing to have a family conference recorded. Our results suggest that clinicians in the intensive care unit may improve the experiences of families of critically ill patients by providing explicit support for decisions made by a family with regard to end-of-life care and by assuring families continuity of high-quality care with particular attention to the patient's comfort.

Improvement of clinical care requires measurement of key dimensions of health care quality and action based on these measurements. Families, data analysts, clinicians, and administrators all have important roles to play.To outline an approach to the measurement and utilization of family satisfaction data so that these data can be translated into health care quality improvement initiatives.Using a synthesis of existing knowledge about translation of satisfaction data into improvement strategies, this approach starts with selecting and implementing a satisfaction survey that reflects the key processes, providers, and places for the delivery of critical care. The survey results can be expressed in a way that prioritizes the opportunities for improvement. A comparison of results across sites, or use of a performance-importance grid, can assist in this prioritization process. High-priority items can then be addressed by the multidisciplinary intensive care unit team using a systematic, evidence-based approach to improvement that includes implementation strategies that have been proven to effectively change clinician behavior.

Family members of critically ill patients report dissatisfaction with family-clinician communication about withdrawing life support, yet limited data exist to guide clinicians in this communication. The hypothesis of this analysis was that increased proportion of family speech during ICU family conferences would be associated with increased family satisfaction.Cross-sectional study.We identified family conferences in intensive care units of four Seattle hospitals during which discussions about withdrawing life support were likely to occur.Participants were 214 family members from 51 different families. There were 36 different physicians leading the conferences, as some physicians led more than one conference.Fifty-one conferences were audiotaped.We measured the duration of time that families and clinicians spoke during the conference. All participants were given a survey assessing satisfaction with communication.The mean conference time was 32.0 mins with an sd of 14.8 mins and a range from 7 to 74 mins. On average, family members spoke 29% and clinicians spoke 71% of the time. Increased proportion of family speech was significantly associated with increased family satisfaction with physician communication. Increased proportion of family speech was also associated with decreased family ratings of conflict with the physician. There was no association between the duration of the conference and family satisfaction.This study suggests that allowing family members more opportunity to speak during conferences may improve family satisfaction. Future studies should assess the effect of interventions to increase listening by critical care clinicians on the quality of communication and the family experience.

ObjectiveTo develop and validate the Critical Care Family Satisfaction Survey as a proxy for patient satisfaction.DesignInstrument validation study.Setting and Time FrameThe Medical Intensive Care, Shock Trauma, Acute Coronary Care, Central Nervous System, Surgical Intensive Care, and Special Care u

A growing body of evidence demonstrates the importance of end-of-life care in the ICU. The ICU is a common place of death, as approximately one fifth of all deaths in the United States occur during or soon after a stay in the ICU (1). Many studies have documented regional and interhospital variability in the intensity of treatment at the end of life, but variability in family assessments, nurse assessments, and specific quality markers for palliative and end-of-life care in the ICU has not been as thoroughly examined (2–4). The Study to Understand Prognosis, Preferences, and Risks of Treatment (SUPPORT) showed that the quality of end-of-life care for seriously ill hospitalized patients was poor between 1989 and 1994 with a high burden of pain and other symptoms, and many patients receiving treatments they would not choose (5). SUPPORT also found that, for 50% of the patients, physicians were unaware of preferences for intensity of care at the end of life (5–7). Two recent trends raise the possibility that palliative and end-of-life care in the ICU may have improved over time: 1) the increasing emphasis on providing palliative care to patients in critical care settings (8–11) and 2) findings from recent studies reporting relatively high levels of family satisfaction with care in the ICU (12–14). Despite these important trends (15), there are few studies examining improvement in the delivery of palliative and end-of-life care in the ICU over time. We were interested in examining interhospital variability and temporal trends in the quality of palliative and end-of-life care in the ICU. We used data from a recent cluster-randomized trial of a quality-improvement intervention designed to improve palliative and end-of-life care in the ICU (16) to ask two questions: 1) Is there significant variability across individual hospitals in the quality of end-of-life care in the ICU, as defined by family and nurse ratings and by chart-based indicators of palliative care? and 2) Is there evidence that this quality of care has improved over time within institutions? Based on the prior literature, we hypothesized significant differences between individual hospitals and improved quality of end-of-life care in the ICU over time.

Family satisfaction with critical care is influenced by a variety of factors. We investigated the relationship between measures of organizational and safety culture, and family satisfaction in critical care. We further explored differences in this relationship depending on intensive care unit survival status and length of intensive care unit stay of the patient.Cross-sectional surveys.Twenty-three tertiary and community intensive care units within three provinces in Canada.One thousand two-hundred eighty-five respondents from 2374 intensive care unit clinical staff, and 880 respondents from 1381 family members of intensive care unit patients.None.Intensive care unit staff completed the Organization and Management of Intensive Care Units survey and the Hospital Survey on Patient Safety Culture. Family members completed the Family Satisfaction in the Intensive Care Unit 24, a validated survey of family satisfaction. A priori, we analyzed adjusted relationships between each domain score from the culture surveys and either satisfaction with care or satisfaction with decision-making for each of four subgroups of family members according to patient descriptors: intensive care unit survivors who had length of intensive care unit stay14 days or14 days, and intensive care unit nonsurvivors who had length of stay14 days or ≥14 days. We found strong positive relationships between most domains of organizational and safety culture, and satisfaction with care or decision-making for family members of intensive care unit nonsurvivors who spent at least 14 days in the intensive care unit. For the other three groups, there were only a few weak relationships between domains of organizational and safety culture and family satisfaction.Our findings suggest that the effect of organizational culture on care delivery is most easily detectable by family members of the most seriously ill patients who interact frequently with intensive care unit staff, who are intensive care unit nonsurvivors, and who spend a longer time in the intensive care unit. Positive relationships between measures of organizational and safety culture and family satisfaction suggest that by improving organizational culture, we may also improve family satisfaction.

The study examined the effect of adding a full-time family support coordinator to the surgical intensive care unit team on family satisfaction, length-of-stay, and cost in the surgical intensive care unit.A quasi-experimental design was conducted in two phases: baseline (8 mos) and intervention (10 mos) phases. Data on family satisfaction, length-of-stay, and costs from both phases were collected.The intervention added a new role, the family support coordinator, to the surgical intensive care unit team. The family support coordinator functioned as a liaison between the patient's family and the health care team.The results revealed that generally the intervention was associated with increases in family satisfaction with communication for all surgical intensive care unit team members, with physicians, social workers, and respiratory care therapists showing increases in significance. The largest increase was for physician communication (p = .0034). Families also rated their perceptions of the quality of care provided to their family members by various members of the surgical intensive care unit team. Mean ratings increased for all areas of care, with respiratory and nursing care showing the largest increases. Families' perceptions of the care and treatment they received during the stay of their family member showed increases in all areas of satisfaction between baseline and intervention, particularly those areas most related to the intervention.The implementation of the family support coordinator intervention increased family satisfaction across a range of parameters. Although there were decreases in length-of-stay and costs, they were not statistically significant. Further research is needed to determine whether intervention refinement could produce lower length-of-stay and costs.

There is growing recognition of the importance of spiritual care as a quality domain for critically ill patients and their families, but there is a paucity of research to guide quality improvement in this area. Our goals were to: 1) determine whether intensive care unit (ICU) family members who rate an item about their spiritual care are different from family members who skip the item or rate the item as "not applicable" and 2) identify potential determinants of higher family satisfaction with spiritual care in the ICU.Cross-sectional study, using data from a cluster randomized trial aimed at improving end-of-life care in the ICU.ICUs in ten Seattle-area hospitals.A total of 356 family members of patients dying during an ICU stay or within 24 hrs of ICU discharge.None.Family members were surveyed about spiritual care in the ICU. Chart abstractors obtained clinical variables including end-of-life care processes and family conference data. The 259 of 356 family members (73%) who rated their spiritual care were slightly younger than family members who did not rate this aspect of care (p = .001). Multiple regression revealed family members were more satisfied with spiritual care if a pastor or spiritual advisor was involved in the last 24 hrs of the patient's life (p = .007). In addition, there was a strong association between satisfaction with spiritual care and satisfaction with the total ICU experience (p.001). Ratings of spiritual care were not associated with any other demographic or clinical variables.These findings suggest that for patients dying in the ICU, clinicians should assess each family's spiritual needs and consult a spiritual advisor if desired by the family. Further research is needed to develop a comprehensive approach to ICU care that meets not only physical and psychosocial but also spiritual needs of patients and their families.

To refine the Family Satisfaction in the Intensive Care Unit (FS-ICU) survey and develop a validated method for scoring the instrument.Instrument development study, using data from two prospective cohort studies.Intensive care units in seven university-affiliated hospitals (six Canadian, one United States).Family members of ICU patients.Based on a priori criteria, items were tagged for potential removal and discussed with the FS-ICU developers. Factor analysis was used to test the conceptual structure of the instrument and develop a scoring method based on scales and subscales. The new scoring method was validated in the U.S. cohort using the Quality of Dying and Death (QODD) instrument and nurse-assessed quality indicators.A total of 1,038 family members completed the FS-ICU across seven sites. Fifteen items were initially tagged for possible removal. After consensus with the developers, ten items were dropped (and 24 were retained in the final instrument). Factor analysis explained 61.3% of the total variance using a two-factor model. The first factor pertained to satisfaction with care (14 items). The second factor encompassed satisfaction with decision making (10 items). A scoring method was developed based on this conceptual model. In validity testing, the FS-ICU was significantly correlated with the Family-QODD total score (Spearman's .56, p.001) as well as individual QODD items such as quality of care by all providers (.64, p.001). The FS-ICU also correlated significantly with multiple nurse-assessed quality indicators.The shortened FS-ICU measures two main conceptual domains-satisfaction with care and satisfaction with decision making. Scores on the FS-ICU show good validity against other indicators of ICU quality. The instrument holds promise as a useful outcome measure in studies that attempt to improve this component of ICU care.

Our objective was to discuss obstacles and barriers to effective communication and collaboration regarding end-of-life issues between intensive care unit nurses and physicians. To evaluate practical interventions for improving communication and collaboration, we undertook a systematic literature review. An increase in shared decision making can result from a better understanding and respect for the perspectives and burdens felt by other caregivers. Intensive care unit nurses value their contributions to end-of-life decision making and want to have a more active role. Increased collaboration and communication can result in more appropriate care and increased physician/nurse, patient, and family satisfaction. Recommendations for improvement in communication between intensive care unit physicians and nurses include use of joint grand rounds, patient care seminars, and interprofessional dialogues. Communication interventions such as use of daily rounds forms, communication training, and a collaborative practice model have shown positive results. When communication is clear and constructive and practice is truly collaborative, the end-of-life care provided to intensive care unit patients and families by satisfied and engaged professionals will improve markedly.

“Qualitative analysis of an intensive care unit family satisfaction survey” by Dr. Henrich and colleagues (1) in this issue of Critical Care Medicine is an excellent multisite study that evaluates the intensive care unit experience directly through feedback from family members. The study analyzed th

Introduction: Intensive care unit (ICU) noise is known to have deleterious effects on sleep, healing, stress levels and recovery times as well as patient and family satisfaction. With this in mind, we engaged in a multidisciplinary effort to reduce noise through a variety of interventions. Methods