MyICUCare.org - Society of Critical Care Medicine

Evaluating ICU Care in Your Community

Ensure That You Will Receive the Best Quality Care: 6 Topics to Discuss With Your ICU

Most of us do not think about having to be admitted to a hospital, let alone an intensive care unit (ICU) where patients with life-threatening illnesses and injuries are treated.

Yet, more than 5 million patients are admitted to ICUs each year in the United States. Four out of five of us will experience intensive care during our lifetime, either as a patient or as family member or close friend of a patient. Only the sickest of patients are admitted to the ICU: patients who need intensive care, constant monitoring, and temporary support while they recover. This care may be necessary over a period of hours, days, or weeks. Although most people recover, some of the patients may die despite receiving the best possible medical and nursing care.

When the need for intensive medical treatment in an ICU for you or your family member arises, you must already have an understanding of the medical care you or your loved one are about to receive. Thus, it is important to think about medical treatment before such care is needed. Medical studies have shown that there is a wide variation in the treatment received in hospitals and ICUs. Some ICUs provide a higher level of care than others. For example, some hospitals use higher nurse-to-patient ratios, which means that each nurse takes care of fewer patients. The good news is that you can learn what to look for and what to ask to ensure you or your loved one receives safe and high quality care.

Did you know that most—but not all—hospitals have an ICU?

Because more than 70% of hospitals have an ICU, finding one in your area should not be difficult.

Small hospitals tend to have one ICU for all types of care. Large hospitals, especially teaching institutions, often have more than one type of ICU. The most common kind of ICU is the medical/surgical/respiratory ICU, which offers many different types of critical care monitoring and treatment. In large hospitals, these types of care may be divided into separate ICUs.

Specialized ICUs include the cardiac ICU, also referred to as the coronary care unit or CCU, which provides heart monitoring and treatments for patients with conditions such as heart attack, angina, irregular heart beat, and heart failure. The trauma/burn ICU offers injury and wound care, as well as treatment for patients involved in car accidents or with gunshot injuries. The neurologic ICU provides brain and spinal cord monitoring and treatments for patients who have head injuries or a stroke. An ICU specializing in the care of children is a pediatric ICU, also called PICU, and offers critical care for children from birth through their teenage years. A neonatal ICU, also called NICU, provides care for babies within the first 28 days of life.

This booklet is designed to help you evaluate the quality of care and some of the optional services provided in ICUs in your community. It not only lists important questions to ask, but it also explains why these questions are important. This booklet also provides resources to help you find more information.

This booklet covers six topics that relate to the quality of care provided in the ICU. The importance of each topic is briefly explained, and questions for each topic are provided. Although you may not understand each and every term used or all of
the questions for each topic, you will still be able to judge the answers because the more positive they are, the better. Also, it is important to note how many items on the checklist are being followed in the ICU.

The questions should be answered by ICU staff. You will find a copy of all the questions at the end of this booklet. It will serve as your checklist. Tear out pages 13-16, make copies, and go to the hospital(s) in your area. Ask to speak to the manager of critical care services or intensive care services. It could be someone like a nurse manager or a physician director. Tell the healthcare provider that you are evaluating ICUs in your area to help you and your family decide which hospital would be best for your care. Give the healthcare provider a copy of the checklist and ask him or her when you can pick up the completed form. You could also provide a self-addressed envelope so he or she can mail it to you. Make sure to let the healthcare provider know how important this is to you and your family and how much you appreciate this information.

Resources

At the end, there is a checklist for ICU staff and list of resources to help you find more information.

Topic 1: How Can I Be Sure This ICU Provides Safe, High Quality Care?
Care provided in the ICU is complex, because the patients who are admitted have life-threatening illnesses or injuries. Sometimes ICU care requires state-of-the-art medical equipment, such as a mechanical ventilator to help patients breathe or a machine to monitor the heart, as well as other devices. ICUs should be staffed by specially trained physicians, nurses, and other medical professionals from many different specialties. More importantly, all these ICU professionals must work together as a team to deliver care quickly and safely.

When complex care is provided, errors can happen. One in five ICU patients may be affected by a serious adverse event, or hospital error—that is, an unexpected event that could cause harm to the patient, such as the patient falling or receiving the wrong kind or amount of medication.

In recent years, many national organizations have focused on the quality of care being provided by the nation’s hospitals, and specifically in the ICU. Among those organizations are The Joint Commission, The Leapfrog Group, and the National Quality Forum (NQF). The Society of Critical Care Medicine (SCCM), which is the leading organization of healthcare professionals working in critical care, and the American Association of Critical-Care Nurses (ACCN), which provides nursing certification, education, research, and support, both serve the special needs of severely ill and injured patients. These organizations have standards and guidelines for ICU professionals to follow in order to provide safe and high quality patient care.

ICU professionals can improve the care they provide by following the standards and guidelines set by these national organizations and keeping up with the latest research in critical care. When studies identify new ways to save lives or reduce patient complications and suffering, the best ICU caregivers quickly change their practice. They may use evidence-based care, best practices, or quality improvement efforts to improve ICU care. They may use tools such as quality indicators, patient safety monitoring, medical error reporting, and report cards to measure the safety of provided care.

Hospitals evaluate rates to improve the quality and safety of ICU care. These include the following:

Mortality (death rate) and morbidity (how often patients develop other illnesses or problems while in the ICU)
Adverse events and near misses
Complications
Infections
Readmission to the ICU within 24 hours
Length of ICU stay
Patient and family satisfaction

Quality of Care Questions

How well did this hospital do on its most recent Joint Commission survey? It received:
Accreditation
Provisional or conditional accreditation
Preliminary denial or denial of accreditation
Preliminary accreditation
Does this institution meet The Joint Commission’s National Patient Safety Goals? It meets:
Less than half of them
Half of them
Most of them
All of them
Does this ICU follow the list of 30 Safe Practices for Better Healthcare developed by NQF? It meets:
Less than half of them
Half of them
Most of them
All of them
Does this ICU meet The Leapfrog Group’s safety standards? It meets:
None of them
Half of them
All of them
Are AACN practice alerts used in this ICU?
All of them
Some of them
None of them
Are SCCM guidelines used in this ICU?
All of them
Some of them
None of them
Does this ICU have a method in place for ICU safety and error reporting?
Yes
No
Does this ICU use measures to regularly monitor and improve the quality and safety of ICU care?
Yes
No
Does this ICU use a daily checklist to coordinate and clarify the goals for ICU patients?
Yes
No
Have any of these programs improved patient care and reduced errors in this ICU?
Yes
No

Topic 2: How Do I Know That the ICU Will Have Qualified Doctors and Nurses?
Intensive care is a specialty area for physicians. Physicians who are board-certified in a medical specialty, such as surgery, internal medicine, pediatrics, or anesthesiology, and who also receive special education, training, and subspecialty certification specifically in critical care are called intensivists. Board certification reflects advanced training, skills, and knowledge in diagnosing and treating critically ill and injured patients. Intensivists may be assigned to the ICU on a full-time basis and work with other critical care team members to provide their patients with ongoing and consistent care.

ICU nurses must also have specialized training and experience. They may be certified by the American Association of Critical-Care Nurses through more specialized education, training, and testing, and are recognized as a “CCRN.” ICU nurses provide a high level of skilled nursing for total patient care and often facilitate communication between all of the people involved in the care of the patient. Their expertise and continuous presence allows early recognition of subtle, but significant, changes in patient conditions, thereby preventing worsening conditions and minimizing complications that arise from critical illness. Having an adequate number of these specialized nurses, around the clock, is the standard of care in ICUs providing safe and high quality care.

Other key members of the ICU team are a specially trained pharmacist, respiratory therapist, nutritionist, and social worker. ICU pharmacists are board-certified specialists in the science and clinical use of medications. The ICU pharmacist is equipped in recognizing the needs and problems specific to the critical care patient and works with members of the healthcare team to foster effective and safe medication therapy. Respiratory therapists work with the critical care team to monitor and promote airway management of the patient. This may include oxygen therapy, mechanical ventilation (breathing machine) management, aerosol medication therapy, and patient and caregiver education. The nutritionist is a vital part of the medical team that consults with physicians, nurses, therapists, and family members in the ICU. The nutritionist works to improve the nutritional health and promotes recovery of the patient. The social worker is a licensed professional that works with the ICU interdisciplinary team to provide a link between treatment plans for the patient and family members. Special knowledge that is acquired through formal, professional social work education, welfare policies and services, and social welfare systems and community resources guide the practice of this work.

Staffing Questions

Is the medical director of this ICU an intensivist?
Yes
No
Is there a physician in this ICU during the day or available within 5 minutes in an emergency?
Yes
No
How many days a week is a physician in the ICU or available within 5 minutes in an emergency?
Everyday
5 days a week
How many nights a week is a physician in the ICU or available within 5 minutes in an emergency?
Everyday
5 days a week
What is the typical nurse-to-patient ratio in this ICU?
1:1
2:1
3:1
4:1
How many ICU nurses in this ICU are CCRN certified?
All of them
Most of them
Half of them
Less than half of them
None of them
Does the ICU have a pharmacist, respiratory therapist, nutritionist, and social worker working only in the unit?
Yes
No

Topic 3: How Well Does the Team of ICU Caregivers Communicate With the Patient/Family and With Each Other?
Providing safe, quality ICU care requires input and cooperation from all members of the ICU team. This includes the patient and family members who should be encouraged to participate in decision-making.

Good communication between the caregivers, patient, and family is important for making sound decisions about treatment options, including surgery, tests, the use of machines and monitors, and drugs. It also helps to reduce the stress and anxiety of critical illness. The healthcare professional with overall responsibility for the patient’s care should be identified quickly upon admission to the ICU.

Ideally, patients should be a part of the discussions with the ICU team to make decisions about their treatment. But, often times, the ICU patient is too sick and family members must make those decisions. If the patient is unable to be involved, then one family member may be named the spokesperson to meet with the ICU team and to be the contact person for both the caregivers and the family.

ICU healthcare professionals should speak with the patient and family daily about the plan of care, the patient’s response to treatment, what to expect, and the goals the team has set to determine how the patient is improving. This information should be relayed in a clear, easily understood, and timely manner.

Many ICUs have a policy that healthcare professionals should ask if the patient has an advance directive, that is, a document that states the patient’s healthcare choices or names someone to make the choices if he/she is unable to do so. This may be a living will or a durable power of attorney for health care. Having an advance directive can serve to guide the decision-making for family members. Having these conversations before the patient becomes critically ill can make difficult decisions easier to make.

ICU healthcare professionals providing high quality care will conduct a formal patient or family care conference when the patient’s medical problems are many, his or her condition changes dramatically, or the patient’s progress is evaluated. The best ICU caregivers conduct conferences routinely for all their patients. At the conference, several members of the ICU team will meet with the patient and family to answer questions about the care plan. Family members can ask an ICU nurse to arrange a conference or even to speak with certain members of the ICU team. Printed information may be passed out at that time. Some institutions have what may be called a family liaison or patient advocate to help families.

Communication among members of the ICU team is also important to promote a sense of teamwork, avoid errors, and provide safe, high quality patient care. This is especially important in the ICU when caregivers change shifts.

Communication Questions

Will I be told the name of the primary doctor responsible for the patient’s overall care?
Always
Usually
Only if you ask
Will I get frequent updates from the ICU team? Routinely and when significant changes occur
When significant changes occur
Only when you ask
Will I be able to read or see the contents of the patient’s medical record?
Yes
No
Is there someone on staff who could provide information about an advance directive?
Yes
No
May I request a patient/family conference?
Yes, it is encouraged
Yes, it is possible
It is not encouraged
Will I get printed information about what to expect during an ICU stay?
Yes, we provide an information packet
Yes, we provide some materials
No
Does the institution have a family liaison or patient advocate?
Yes
No
Do the nurses use a formal system for reporting to each other at the end of each shift?
Yes
No
Is there a procedure for physicians to safely transfer responsibility to the next physician at the end of a work shift?
Yes
No

Topic 4: Can I Stay With the Patient in the ICU?
Family members and close friends value being able to stay with or near the patient during his or her ICU stay. This can help relieve stress and promote healing. Although many hospitals have flexible visiting hours for these reasons, their ICU visiting schedules vary widely. They vary by time of day, who they allow to visit, and how many visitors are allowed at the same time. Some ICUs let only members of the immediate family visit, while others allow significant others. Some ICUs allow young children under the age of 12 and even pets to visit. However, the primary concern is the patient. If he or she does not seem to do well during the visit, ICU staff may suggest how the family can better interact with the patient or ask the family to visit only for very short periods of time.

While some family members want to be close by to show their support, others may want to be involved in patient care or to be there during certain procedures. Some hospitals are changing their policies to allow family members to be present at such times. In addition, some ICUs allow families to join the medical and nursing team on rounds, during which the patient’s condition, as well as diagnostic and treatment plans, is discussed.

Having lounges and waiting rooms reserved for family members of ICU patients may help reduce the stress of the experience. Family members spend a lot of time waiting, and being able to do so in a comfortable and convenient area is important. Some hospitals offer a lounge where visitors can sleep, use a telephone or computer, watch television, and get refreshments.

Family in the ICU Questions

Are visiting hours restricted during the day and/or evening?
Yes
No
Who can visit?
All significant others
Adult family members
Only immediate family members
Family members under the age of 12
Pets
How many visitors can visit at the same time?
As many as the patient would like
1 or 2 at a time
Does this ICU have a policy in use to encourage family members to participate in patient care?
Yes
No
Does this ICU have a policy in use that allows family members to be present for procedures?
Yes
No
Does this ICU allow families to join the medical and nursing team when they round to my loved one?
Yes
No
Which of the following does the facility provide for ICU patient family members?
ICU waiting room
Seating for small groups
Private areas
Kitchen facilities
Lockers
Shower facilities
Sleep facilities
Volunteer or staff in the waiting area to help meet family needs

Topic 5: How Can I Be Sure the Patient’s Pain and Suffering Will Be Managed?
Sometimes treatments given to ICU patients to save their lives may cause pain or discomfort. Just being in the ICU can cause fear and distress. Patients may become anxious, angry, or confused.

Members of the ICU team should ask the patient if he or she is having any pain and, if so, to describe it. Depending on the patient’s condition and ability to understand or respond, the caregiver may use pain scales to get a better sense of the patient’s pain. ICU staff should be able to give information about different pain relief measures, respond quickly to any report of pain, and manage it in a timely fashion. If the patient is experiencing anxiety or agitation, he or she may be given medication to relax, because being very anxious can interfere with getting better. Staff can also take measures to prevent pain and anxiety from occurring. Once the patient has been treated, caregivers should check regularly on the patient’s symptoms to make sure the treatment is working. Pain and anxiety can also be relieved with techniques to relax or distract the patient.

Sometimes the patient is suffering from emotional issues or has spiritual needs that have not been met. Most hospitals have clergy members as part of the ICU team who can talk with the patient and family about their spiritual needs, which may involve religious beliefs or the patient’s sense of life purpose or sense of loneliness. Spiritual or religious beliefs may tie into the patient’s ethnicity and cultural background. These beliefs can affect how he or she thinks about having a critical illness, if the patient will follow treatment, how much information he or she wants to know, or how much the family will be involved in decision-making.

ICU caregivers do not just provide top-notch critical care. They should also focus on ways to ease the physical, spiritual, and emotional pain and suffering of the patient and family. This is true for both patients who are getting better and those who have reached the end-of-life stage.

The environment of care also plays a role in the patient’s healing. For example, patients treated in noisy surroundings and artificially lit rooms do not recover as quickly as those staying in quieter rooms with natural light.

Relief of Pain and Suffering Questions

Does this ICU use a formal method to assess the patient’s pain or discomfort?
Always
Usually
Sometimes
Never
Does this ICU use a formal system in use to regularly evaluate the patient for anxiety and agitation?
Always
Usually
Sometimes
Never
Does this ICU use a formal method to regularly evaluate the patient for confusion or delirium?
Always
Usually
Sometimes
Never
Are specialists in pain management and other forms of emotional distress available and utilized in this ICU?
Always
Usually
Sometimes
Never
Is a member of the clergy available to meet the spiritual needs of the patient and family?
Always
Usually
Sometimes
Never
Is it ICU policy to honor the patient’s cultural beliefs?
Always
Usually
Sometimes
Never
Does the ICU environment promote healing by keeping noise levels down and using natural lighting?
Yes
No

Topic 6: What Should I Expect to See in the ICU That Will Assure Me the Patient is Being Treated With Respect and Dignity?
Patients and their families should expect to be treated with respect and dignity during this stressful time. The ICU staff should keep the patient and family up-to-date on the patient’s condition, work with them to make sound decisions, and honor the patient’s values and preferences for treatment. In recent years, many institutions have adopted a Patient Bill of Rights. In brief, the patient has the right to the following:

Considerate and respectful care

Complete current information about his or her diagnosis, treatment, and prognosis explained in a way that is understood
Enough information about a treatment to be able to give informed consent (that is, agree to have it done) or to refuse treatment
Protected privacy
Confidential medical records and communications

Most patients admitted to an ICU get better and go home. But, sometimes lives cannot be saved. In those cases, ICU caregivers can offer comfort care—or palliative care—during the patient’s end-of-life stage. This means that treatments causing discomfort would be avoided. Easing the patient’s suffering and controlling his or her pain may be the best way to respect the patient’s dignity. During the patient’s final stage of life, ICU caregivers should work with the family to honor the patient’s wishes, provide comfort, and offer support for the family.

Respect and Dignity Questions

Does the ICU team promote shared decision-making with the patient and/or family members?
Always
Usually
Sometimes
Never
Is there an ICU policy in use that describes what happens when the patient/family and the ICU caregivers disagree about treatment?
Yes
No
Can I see the hospital’s Patient Bill of Rights or patient rights and responsibility information?
Yes
No
Is it the ICU policy for ICU staff to seek out and honor the patient’s values and preferences for treatment?
Yes
No
Which of the following does the ICU have in place?
End-of-life care policy
Palliative care plan
Programs to help grieving families
Does the ICU have a policy that promotes a patient’s right to die with dignity?
Yes
No

Resources for Patients and Families

Topic 1: Quality of Care

Agency for Healthcare Research and Quality (AHRQ)—For information and resources on quality of care, medical errors, and patient safety, visit the Consumers & Patients page at http://www.ahrq.gov/consumer.
AHRQ Patient Safety Network—For information and resources about patient safety, including literature updates, news, tools, meetings and links to research, visit http://psnet.ahrq.gov.
American Association of Critical Care Nurses (AACN)—For practice alerts supported by evidence-based medicine, go to http://www.aacn.org/AACN/practiceAlert.nsf/vwdoc/pa2.
Healthfinder®—For reliable health information on the Internet from more than 1,500 health-related organizations, go to http://www.healthfinder.gov/healthcare. This site was developed by the US Department of Health and Human Services.
HealthGrades®—For ratings and profiles of hospitals and physicians from the leading healthcare ratings company, visit http://healthgrades.com. HealthGrades® also publishes a report on America’s 50 Best Hospitals.
Hospital Compare—To learn how well hospitals in your area care for patients with certain medical conditions, go to the US Department of Health & Human Services’ Hospital Compare Web site at http://www.hospitalcompare.hhs.gov.
Society of Critical Care Medicine (SCCM)—For standards of care guidelines, go to http://www.learnICU.org. You can also visit the SCCM’s official Patient and Family Care Support Web site at www.MyICUCare.org.
The Joint Commission—To learn about The Joint Commission’s National Patient Safety Goals and on-site review, go to http://www.jointcommission. org/GeneralPublic. To learn how well a specific hospital did on its Joint Commission review, go to the bottom of the page and click on Quality Check™ or visit http://www.qualitycheck.org/consumer/searchQCR.aspx.
The Leapfrog Group—To learn about The Leapfrog Group’s hospital quality
ratings, go to http://www.leapfroggroup.org/for_consumers.

Topic 2: Staffing

American Association of Critical Care Nurses (AACN)—For standards of care for critical care nurses and position statements about their role in patient care, go to http://www.aacn.org.
Society of Critical Care Medicine (SCCM)—For a list of medical professionals and other support service professionals who make up the ICU team, go to www.MyICUCare.org/Critical_Care_Team.
The Leapfrog Group—To learn about its patient safety standard for ICU physician staffing, visit www.leapfroggroup.org.

Topic 3: Communication

Society of Critical Care Medicine (SCCM)—For brochures on ICU care and communication, go to http://www.MyICUCare.org. For information about sharing medical information, visit http://www.icu-usa.com/tour/Questions/ yourself.htm. For tips on how to best communicate with children, go to http://www.icu-usa.com/tour/children.html. For information about advance directives, visit http://www.icu-usa.com/legal/advanc_dir.htm.
The National Hospice and Palliative Care Organization (NHPCO)—To learn more about advance directives, living wills, and medical power of attorney, visit http://www.caringinfo.org, the NHPCO’s consumer Web site. State-specific advance directives can be downloaded from the Web site.

Topic 4: Family in the ICU

City of Hope—The institution dedicated to the prevention and cure of cancer and other life-threatening illnesses lists many guest services available to patients and their families on its Web site at http://www.cityofhope.org.
Society of Critical Care Medicine (SCCM) — For the Support of the Family in the Patient-Centered ICU guidelines and brochures titled Participating in Care: What Questions Should I Ask? and Taking Care of Yourself While a Loved One is in the ICU, visit http://www.MyICUCare.org. For information about sharing medical information and visitation, go to http://www.icu-usa.com/tour/waiting_room.html. For information about CPR, visit http://www.icu-usa.com/tour/procedures/cpr.htm.
SupportCircle.com—To make it easier for family and friends to communicate and support each other during a time of crisis, such as an ICU stay, when communication is at its most difficult, go to www.supportcircle.com to create an online page.

Topic 5: Relief of Pain and Suffering

American Pain Society (APS)—For an online resource for people with pain, their families, friends, and caregivers, the APS launched the American Pain Foundation Web site that offers guidelines and publications at http://www.ampainsoc.org/people. More information can be found at http://www.nationalpainfoundation.org.
Growth House, Inc.—To learn about life-threatening illness and end-of-life care, go to http://www.growthhouse.org/palliat.html. This Web site offers resources for palliative care and pain management.
Hospice—For information on such topics as dispelling the myths of pain control, relieving pain without medicine and helping yourself live while dying, visit http://www.hospicenet.org.
Hospice and Palliative Nurses’ Association—For position statements on issues, such as providing artificial nutrition and hydration, sedation, and complementary therapies at end of life, visit http://www.hpna.org.
Promoting Excellence in End-of-Life Care—This Robert Wood Johnson Foundation (RWJF) program offers innovative models and approaches for palliative care. The Web site, http://www.promotingexcellence.org, lists many tools that can be used by caregivers to improve palliative care. Patients and family members might want to learn about tools for pain management, spiritual assessment, informed consent and care planning, among others.
Society of Critical Care Medicine (SCCM)—For a brochure entitled Palliative Care for Children, visit www.MyICUCare.org.
The Center to Advance Palliative Care—This organization provides training for healthcare professionals and launched a Web site for patients and families at http://www.capc.org.

Topic 6: Respect and Dignity

DyingWell.org—This Web site, http://www.dyingwell.org, offers written resources and referrals to organizations, Web sites, and books to empower persons with life-threatening illness, and their families, to live fully.
Five Wishes™—RWJF created the document entitled Five Wishes™ that is different than other living will forms, because it looks at a person’s medical, personal, emotional, and spiritual needs. Information about Five Wishes™ is available at www.agingwithdignity.org/5wishes.html.
Growthhouse.org.—To learn about death with dignity, visit http://www.growthhouse.org/dignity.html. This Web site offers resources for palliative care and hydration, as well as withdrawing life-sustaining treatment.
Society of Critical Care Medicine (SCCM)—A DVD entitled Compassionate Care in the ICU created to assist family members in helping their loved ones obtain the best and most appropriate care when in the ICU. To get a copy, call (847) 827-6869. To get a copy of a patient’s bill of rights and responsibilities used by most hospitals, visit http://www.icu-usa.com/icu/bill_of_rights.html.
The National Hospice and Palliative Care Organization (NHPCO)—To learn about options for end-of-life services and care, as well as plans to ensure that the patient’s wishes are honored, the NHPCO’s consumer Web site, http://www.caringinfo.org, offers free resources and information. Among them are a brochure entitled Let’s Start Talking available at http://www.nho.org.