Survey of Family satisfaction and decision making in polytrauma patients in intensive care unit

INTRODUCTION

Attending to the needs of family members of critically ill patients is necessary step in providing appropriate holistic care for both the patient and the family. Family interaction can significantly impact on the experience of critical illness, notwithstanding the challenge of meeting families’ needs for many clinicians in the intensive care unit (ICU).  ICUs are highly technological wards where critically ill patients receive treatment and nursing care. The reasons for admission to intensive care are many and complex. The patient’s recollections of the ICU stay may consist of unclear memories and hallucinations caused by ICU delirium as well as actual events. Studies show that patients can develop post-intensive care syndrome (PICS) as a result of the ICU stay. Becoming critically ill represents not merely a great upheaval for the patient but also for their close family. Family members play a key role as both mediators of the intensive care patient’s needs and wishes and as a health-promoting resource that can improve patient outcomes. Family members’ needs and wishes are important in terms of both their role as supporters for the patients, and their own personal needs. Studies show that there may be a high prevalence among of depression, post-traumatic stress disorder (PTSD) or PICS-Family at the end of an ICU stay among family members.

Many families experience the time spent in the ICU as challenging and full of uncertainty regarding the intensive care patient’s condition, treatment and prognosis. Family members describe the experience and the sight of the intensive care patient as well as the surroundings of the hospital bed, as frightening and unreal. They want to participate in patient care and be included in decision-making processes. Dodek et al and Wall et al.[15] showed that there is a potential for improvement in respect of the family’s perceptions of receiving support in the decision-making processes. Information exchanges where the ICU nurse is not present can make further communication between them and the family members more difficult.  Nevertheless, family members describe the support they receive from the ICU nurses as crucial for them in coping with the situation and understanding what is happening.

In recent years, the patient’s perceptions of quality of care or satisfaction and the views of their family have been highlighted and used as one of several internationally recommended quality indicators for intensive care medicine. Frivold G[11] asserts that client satisfaction is very important as a measurement of the quality of medical services and provides information about whether health personnel have successfully responded to the client’s values and expectations. However, on account of their illness and treatment, it can be challenging for patients to evaluate the ICU stay. Studies [12]show that the patient’s and the family’s perception of an ICU stay can be the same. In recent years, knowledge about the experiences of the patient and their family during the ICU stay has resulted in increased research on family satisfaction.

Although there is much enthusiasm among ICU doctors in India to boost the quality of health care, medical resources, particularly in the ICU and hospital, are not sufficient to fulfill the continuing needs of family-centered care. Hence, it is worthwhile to survey FS-family satisfaction with patient care and involvement in decision making about their patients in ICU. Many questionnaires have been devised for estimating family satisfaction about the ICU experience. Among them, the family satisfaction in the ICU questionnaire (FS-ICU) has convincing validation.[12]

Family satisfaction with the care received by the patient during an ICU stay can be an important piece of information used in overall ICU quality enhancement, ensuring that the care provided meets both the patient’s and the family’s needs. Few quantitavestudies on family satisfaction following an icu stat have been published in Norway[20]. More knowledge is vital for both safeguarding the needs of family members and for assessing transferability between national and international research. It is also important to investigate how different demographic variables affect family members’ satisfaction ratings.

Communication interventions help promote family involvement in their loved one’s care and facilitate their decision-making capacity, as well as improving clinician and family interaction, family comprehension of their loved one’s condition and also reduce the development of post-traumatic stress-related symptoms. Family satisfaction may be increased with the provision of comfortable physical environments with noise reduction measures. More rigorous high-quality studies investigating interventions to meet the needs of family with a relative in ICU are needed.

AIMS AND OBJECTIVES

•         Survey of Family satisfaction and decision making in polytrauma patients in intensive care unit

Primary Objective:

•         To assess family satisfaction with ICU care using the family satisfaction -ICU questionnaire and

•         To assess family satisfaction with decision making around the care of critically ill polytrauma patients using the family satisfaction -ICU questionnaire.

•         Secondary objectives :

•          To identify scope for improvement in family satisfaction

•         To assess patient demographics and socioeconomic factors influencing FS with ICU care and the decision-making process.

METHODOLOGY

Study Settings:

•         The study will be conducted in Department of Anesthesiology- ICU , King George’s Medical University, Lucknow after getting approval of ethical committee.

•         Study design: Prospective single center cross sectional study

•         Study duration:  2 Year

•         Sample size: Approximately 66 cases

Sample Size at 90% Power:

Sample size is calculated on the basis of maximum variation in overall satisfaction Likert scale using the formula,

Where s = 14.7, The maximum SD of overall satisfaction Likert scale

d = 10% of mean satisfaction Likert scale (=64.94), the difference considered to be clinically significant

(ref : Bharadwaj S, Umamaheswara Rao G S, Hegde A, Chakrabarti D. Survey of Family Satisfaction with Patient Care and Decision Making in Neuro-Intensive Care Unit- A Prospective Single Center Cross Sectional Study from an Indian Institute of Neurosciences.Neurol India 2022;70:135-147)

Design effect k = 1

type I error α = 5% corresponding to 95% confidence level

type II error β = 10% for detecting results with 90% power of study

n = 66

Inclusion Criteria:

•         Polytrauma patients of either sex, aged 15-70 years

•         Adult family members of all patients admitted to the ICUs for more than or equal to 48 hours

•         Family member giving written informed consent will be taken

Exclusion criteria

•         Died patients within 48 hours of ICU admission 

•         Not giving consent

Ethical approval:

It will be taken from the Institutional Ethics Committee of the University.

STUDY PROTOCOL

•         The study will be done at King George’s Medical University, Lucknow. This will be a Prospective single center cross sectional study. Patients will be evaluated in the icu by an anaesthesiologist . Family members will be communicated through nursing staff and anaesthesiologist.

A minimum stay of 48 hours will be used to provide adequate exposure of the patient’s attendant to ICU. Study participant will be designated to be the next of kin (NOK) and nominated as the pivotal contact person. Details of Next of kin will be documented on the nursing chart at the time of admission. Questionnaires of patients who died in the ICU after 48 hours and during the study period will be not analyzed. A copy of the questionnaire will be given to the study participant after 48 hours of ICU admission of his/her family member. They will be asked to complete the questionnaire and return it before the patient’s ICU discharge.

Family members will be asked to provide data regarding their age, sex, relationship to the patient, educational level, socioeconomic status, and the frequency of their visits to the patient in the ICU, prior knowledge about the health status of the patient before ICU admission, and ease of travel from home to ICU. Educational level is classified as university degree or equivalent, vocational training or equivalent, or no certified professional training. Socioeconomic status is defined as per modified BG Prasad’s classification-Revised in 2021. Patient characteristics, such as age, sex, Acute Physiology and Chronic Health Evaluation (APACHE) II score, simplified acute physiology score (SAPS) II, and the length of hospital stay, will be collected.

FS-ICU questionnaire :

A short version of the FS-ICU questionnaire consisting of 24 items will be used. Each of these items contained five Likert response options ranging from “poor” to “excellent.” This survey estimated two broad sections.

The first section mainly assessed satisfaction level over a wide range of domains related to ICU care.

The second section concentrated more on satisfaction with decision making.

Written responses will be also obtained for the following open-ended questions by family members.

a) Do you have any recommendations to improve care in the ICU?

b) Do you have any recommendations for improving FS?

c) Please add any comments or suggestions that you feel may help health care workers to provide better care to the patients.

For study participants who will be not comfortable with English, FS-ICU will be translated verbally by a ward nurse who did not render services in the ICU. Patients who will be literate in English answered the questionnaire on their own. Patients who will be illiterate in English took the help of a nurse who will be not working in the ICU to answer the questionnaire. A nurse not working in the ICU will be chosen as we did not want the nurse to influence the response to the questionnaire.
Individual responses of the FS-ICU will be transformed to a scale between 0 and 100. Higher scores on the scale indicated greater satisfaction. The FS-ICU provides the following satisfaction scores: FS-ICU/care (satisfaction with care), FS-ICU/dm (satisfaction with information/decision making), and FS-ICU/total (overall satisfaction with the ICU).

Statistical analysis

Demographic and clinical data of the patients, respondents, and answers to the questionnaires will be presented as either mean (+/�’ standard deviations) and frequency (percentage). After obtaining the responses (LIKERT SCALE) for each item of 66 respondents, they will be linearly transformed into scores by using the formula: transformed value = [(actual item value – lowest possible item value)/possible item range] ×100. Using linear regression models, factors that are significantly associated with FS will be obtained. Significant factors will be represented as a coefficient (standard error) and P values. A P value of 0.05 will be taken as the level for statistical significance.

REVIEW OF LITERATURE

Heyland DK  et al (2002) conducted a prospective cohort study conducted  in  Six university-affiliated intensive care units across Canada. They administered a validated questionnaire to family members who made at least one visit to intensive care unit patients who received mechanical ventilation for >48 hrs. We obtained self-rated levels of satisfaction with 25 key aspects of care related to the overall intensive care unit experience, communication, and decision making. For family members of survivors, the questionnaire was administered while the patient was still in the hospital. For family members of nonsurvivors, the questionnaire was mailed out to the family member 3-4 wks after the patient’s death. A total of 891 family members received questionnaires; 624 were returned (70% response rate). The majority of respondents were satisfied with overall care and with overall decision making (mean +/- sd item score, 84.3 +/- 15.7 and 75.9 +/- 26.4, respectively). Families reported the greatest satisfaction with nursing skill and competence (92.4 +/- 14.0), the compassion and respect given to the patient (91.8 +/- 15.4), and pain management (89.1 +/- 16.7). They were least satisfied with the waiting room atmosphere (65.0 +/- 30.6) and frequency of physician communication (70.7 +/- 29.0). The variables significantly associated with overall satisfaction in a regression analysis were completeness of information received, respect and compassion shown to the patient and family member, and the amount of health care received. Satisfaction varied significantly across sites. Most family members were highly satisfied with the care provided to them and their critically ill relative in the intensive care unit. Efforts to improve the nature of interactions and communication with families are likely to lead to improvements in satisfaction.

Lam SM  et al (2015) conducted a questionnaire based study that  medical-surgical adult intensive care unit in a regional hospital in Hong Kong. Adult family members of patients admitted to the intensive care unit for 48 hours or more between 15 June 2012 and 31 January 2014, and who had visited the patient at least once during their stay. Of the 961 eligible families, 736 questionnaires were returned (response rate, 76.6%). The mean (± standard deviation) total satisfaction score, and subscores on satisfaction with overall intensive care unit care and with decision-making were 78.1 ± 14.3, 78.0 ± 16.8, and 78.6 ± 13.6, respectively. When compared with a Canadian multicentre database with respective mean scores of 82.9 ± 14.8, 83.5 ± 15.4, and 82.6 ± 16.0 (P<0.001), there was still room for improvement. Independent factors associated with complete satisfaction with overall care were concern for patients and families, agitation management, frequency of communication by nurses, physician skill and competence, and the intensive care unit environment. A performance-importance plot identified the intensive care unit environment and agitation management as factors that required more urgent attention. This is the first intensive care unit family satisfaction survey published in Hong Kong. Although comparable with published data from other parts of the world, the results indicate room for improvement when compared with a Canadian multicentre database. Future directions should focus on improving the intensive care unit environment, agitation management, and communication with families.

Maxim T  et al (2019) conducted a study that all patients at a level 1 trauma center were invited to participate in this study after 72 hours of intensive care unit stay. Participants completed a modified version of the Family Satisfaction in the Intensive Care Unit questionnaire, a validated survey measuring family satisfaction with care and decision-making. Data collection spanned from April 2016 to July 2017. Patient characteristics were compiled from the medical record. Quantitative analysis was performed using a 5-point Likert score, converted to a scale of 0 (poor) to 100 (excellent). The overall response rate was 78.6%. Of the 103 family members for 88 patients, most were young (median age: 41 years) and female (75%). Language fluency was 44.6% English-only, 31.7% Spanish-only, and 23.8% bilingual. Mean summary family satisfaction scores (±SD) were 80.6±26.4 for satisfaction with care, 79.3±27.1 for satisfaction with decision-making, and 80.1±26.7 for total satisfaction. Respondents were less satisfied with the frequency of communication with physicians (70.7±27.4) and language translation (73.2±31.2). Overall family satisfaction with the care provided to patients in the TSICU is high, although opportunities for improvement were noted in the frequency of communication between physicians and family and language translation services. Further quality improvement projects are warranted.

Mitchell M  et al (2019) conducted a sequential mixed-methods study was utilised combining survey data and semi-structured interviews. A tertiary Intensive Care Unit in Australia. The Critical Care Family Needs Inventory assessed the needs of families of general and trauma patients. Nurses were also surveyed for their perspectives on the needs of trauma patients’ families. Interviews with families were analysed using an inductive thematic analysis technique. 214 surveys were completed (50 family members of trauma patients; 53 family members of general patients; 111 nurses). No statistically significant sub-scale differences in survey responses between the family groups were found. However, differences on four of the five survey sub-scales (p ≤ .001) were identified between families of trauma patients and nurses. Three themes emerged identifying unique needs of families of trauma patients from the interviews and included: Personal Distress and Adjustment,Guidance, and Care. This mixed methods study identified that families of trauma patients have different needs to families of general patients and the nurses rated the needs of the families of trauma patients as less important than the families rated their own needs. Through a collaborative partnership with these families, nurses can assist and better meet their needs. The provision of individualised patient/family-centred care is likely to have a positive influence.

Haave, R.O  et al (2021) conducted a cross-sectional study  total 57 family members in two ICUs in Norway completed the questionnaire: Family satisfaction in the intensive care unit 24 (FS-ICU 24). Statistical analysis was conducted using the Mann-Whitney U test (U), Kruskal Wallis, Spearman rho and a performance-importance plot. The results showed that families were very satisfied with a considerable portion of the ICU stay. Families were less satisfied with the information they received and the decision-making processes than with the nursing and care performed during the ICU stay. The results revealed that two demographic variables – relation to the patient and patient survival – significantly affected family satisfaction. Although families were very satisfied with the ICU stay, several areas were identified as having potential for improvement. The results showed that some of the family demographic variables were significant for family satisfaction. The findings are clinically relevant since the results can strengthen intensive care nurses’ knowledge when meeting the family of the intensive care patient.

Bharadwaj S  et al (2022) conducted a study that assessed family satisfaction (FS) with intensive care unit (ICU) care and family satisfaction with decision making in the care of critically ill neurological/neurosurgical patients. The FS-ICU questionnaire was used to assess family satisfaction. Data were analyzed using frequency tables and rates. Of the 154 FS-ICU questionnaires analyzed, the overall satisfaction rate with care was 59.97, with information needs was 56.52, and with decision making was 59.46. Lower satisfaction rates among families may be due to the highly morbid nature of neurological illness in their kin or due to differences in socioeconomic factors. Periodic audit of the FS questionnaire is useful in assessing the quality of health care in the neuro-ICU. Efforts to incorporate suggestions of study subjects may improve FS with patient care and decision making.

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Family satisfaction at item and dimension level