Shift change and visitation in ICU/stepdown

*LadyNurse* · Mar 16, 2013

Your facility sounds similar to ours. We restrict visiting from 0630-0730 and 1830-1930. In Our ICU there are only 2 visitors per patient and no children under the age of 10.

We are currently in the process of revising our policies and attempting to make it better. The problem in our unit is that there is a constant influx of patient family members and visitors with total disregard for the nurses. The previous admin tended to side the the "customer" and it seemed like our ICU visiting policy wasn't utilized. When we could ask visitors to leave or adhere to the 2 person limit, they would get upset and "report" the nurse. It was extremely frustrating.

Now we have new admin and management. Apparently they are focused on family centered care and apparently studies have shown that patient morale (not to mention satisfaction scores) have improved with the initiation of the "support person" that is allowed to stay with the patient at all times. They are allowed to stay all night in the ICU as long as they aren't a creating a disturbance or preventing staff from properly caring for the patient. We are going to attempt to place visiting hours at certain times of the day/night. We are still in the early stages of planning. I'm hopeful that it will help.

aei631 · Mar 16, 2013

In the icu I work in we have a no visitors policy from 6a-8a and 6p-8p. Outside of those hours the patient is allowed one 'support' person who may come and go as they please. The are asked to wear an armband that identifies then as the support person and we keep a picture of them in the patient's thin paper chart. Any other visitors are held to visiting hours. There are three times for open visitation on day shift and one at night. A lot of the nurses will let family back during non-visitation hours though if the family is not a problem and it doesn't interfere with care of the patient.

Music in My Heart · Mar 16, 2013

My only experience is as a NICU and PICU parent.

In the NICU, they had a no vistors +/- 30 minutes from shift change. It was sometimes problematic for us as a family. I later did a preceptorship there and they had eliminated that policy, with no significant deleterious effects.

PICU was 24x7 access, soft limit at 2 but were generally OK with 3 or 4.

I'm an advocate of providing unrestricted and unlimited access to the family - but as a privilege, not a right... and privileges can be revoked.

meanmaryjean, DNP, RN · Mar 16, 2013

Our PICU allows parents 24/7 access, others are cut off at 2030, limit three total at bedside and none except siblings under 18. One parent may sleep at bedside, but they can both stay if they are awake.

We have had to restrict visitors to those who will comply with isolation and hygiene policies when that becomes an issue. We are a locked unit, and that helps a LOT.

opossum · Mar 16, 2013

Thanks for all your replies; it's good to get a sense of what policies other ICUs have. Ours is pretty generous, as we let basically anyone in, however many want to come in as long as it doesn't interfere with patient care. We have a locked unit with a camera so we can see who is buzzing in. If there is an entourage waiting to be let in, I'll usually go to the door myself and request 2 or 3 at a time.

We also restrict children under 12. Interestingly, when reviewing the literature, I found that there is no evidence to support restricting children based on fear of infection to either the child or patient (Knutsson and Bergbom, 2007). They actually refer to previous studies that support this...Nurses' and physicians' viewpoints re... [Nurs Crit Care. 2007 Mar-Apr] - PubMed - NCBI

My main issue at this point is whether or not we should pursue this idea of doing away with shift change restrictions altogether. I'm going to see if HIPAA requires it. I would feel it would be in both the patients' and nurses' interests to have adequate time to do report and assess the patient.

Sugarcoma, RN · Mar 17, 2013

We have no visitor restrictions during shift report and it is very challenging. We are a combined ICU/Step-down and we report off in the pods outside of our assigned rooms. There is no privacy. Visitors and sometimes patient's use this as an opportunity to request things, vent frustrations, try to lurk behind us and listen in, etc. etc. It is EXTREMELY frustrating. I find myself having to tell people constantly that they cannot listen in. Often times they become confrontational and I have to tell them I have two patient's and I must protect both patient's private information and that I am sure that you would not appreciate me letting a stranger listen in on report about YOUR loved one. It is frustrating and time consuming. I NEVER leave on time and neither do many of my coworkers.

Based on just my experiences on one unit (so take that for what it is worth) I would say open visitation during report leads to incomplete report (do not want to chance anyone overhearing something like drug use, ETOH, STD's, Psych history etc.), frequent interuptions, and unexpected overtime costs due to nurses leaving later. I also think it contributes to low staff morale.

If we had a designated private room for report like we did on the med-surg unit I worked on I would have no problem with open visitation.

umcRN, BSN, RN · Mar 18, 2013

I work PEDs but we have open visitation for parents and others may come during visiting hours 10a-8 p. We rarely have issues. We only allow two visitors at the bedside and that includes the parents so they have to rotate out. Siblings are allowed as long as they do not have a fever or have had any cold symptoms...this I have a problem with as this past winter we had one of our cardiac kiddos come down with the flu bad (kids never been home in his life). Mom was in an uproar blaming every one of us, until their entire family was taken out by it.

SummitRN, BSN, RN · Mar 18, 2013

We have 24 hour visitation. The other day a patient's family member came out of the room and interrupted report with some information and questions. Luckily, the interruption was brief. I could see it being a major problem at times, but the RN does have control to ask people to leave as needed.

chudder · Mar 20, 2013

We transitioned to a completely open unit and took the locks off the doors in the name of family and patient centered care. The literature presented clearly supports it, and family members love it. Nurses generally hate it, because they treasured the no-visitor shift change time to prep for the shift without any distractions.

It is workable and even beneficial, IMO, if nurses are consistent with what they tell family members about what to expect about shift change and bedside report. After addressing any pertinent questions or needs right before shift change, request no interruption during report. Let them know that you will come into the room to do bedside report and medication and IV line reconciliation with the oncoming nurse, too.

If family members grow to expect a routine, the majority of them will be respectful... in my opinion. There are always outliers.

If it were my family member hospitalized, I would be offended if I were not allowed to be bedside at an hour of any day.. as long as I was not interfering with care.

coco317 · Mar 20, 2013

I work in a combined ICU /step down. Our posted visiting hours are 11-2 and 5-8. Exceptions for patients going for surgery or an invasive procedure. Limit 2 and no one under the age of 12.

Unfortunately, it seems the only ones to follow the rules are the pleasant family members.

There are constant interruptions at change of shift and its very frustrating. Family members like to hang out at the desk and are appalled when we kindly shoo them away because we are discussing private information on other patients.

Recently at a staff meeting, our nurse manager said we are going to have unlimited visiting hours due to JACHO policies. We will still be able to limit 2 visitors.

And just to vent.. Seriously families- please tell me why anyone would think its appropriate to have 8 visitors in a room at once??? It's hard enough to maneuver around with 2 visitors. I'll be damned if they go downhill or code and you're in my way!! Ugh.

Pediatric Critical Care Columnist · Mar 20, 2013

We have an open-door policy on our unit. Sort of. Visitors are required to call the unit from the hallway before they enter. We generally restrict to 2 at the bedside and parents are not permitted to sleep on the unit except in the most extenuating of circumstances. (We simply don't have the space. We have 8 open beds, 7 single rooms and one double room.) Visitors are not asked to leave during shift change or during rounds, but we do close the unit for sternal closures, ECMO cannulation and decannulation and some other procedures. Opinions vary as to whether we should close the unit when a patient is actively dying, during codes and such. Recently a long-term patient of ours who was palliative arrested and died in one of our open beds - in the middle of the big evening crush of visitors. The patient was moved to a private room but the unit was not closed so the other families were witness to these parents' grief. Some felt this was inappropriate and that the unit should have been closed. Others didn't see the point. I'm on the fence.

In terms of logistics, there is very little cause for concern over having families on the unit during shift change or rounds. They are typically respectful of others' privacy (with a few notable exceptions, and we pick up on them very quickly); most don't interrupt during report and are quite patient during assessments. The double room presents some potential issues, but my experience with families in that situation is that they understand the limitations of the space and mind their own business as much as possible. We only have rare complaints over shared space. As one of the PPs has said, education on expectations is key.