Managing 24/7 Visitors
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A brand new ICU patient, whether they are crashing with cardiogenic shock, fresh from the ER in septic shock or just back from the OR, is a busy patient. There are assessments to be done, labs to be drawn and body cavities to be accessed . . . IV, NG, Foley? Intraaortic balloon pump? Chest tubes? But often times family haven't seen the patient since they kissed them goodbye in the pre-op holding area or at the front door this morning. If possible, it's good to have the family back briefly to see the patient and to get a quick update of all that's being done to help them. If the bedside nurse is too busy, overwhelmed or crazed to deal with family right now, perhaps the charge nurse or a neighboring nurse who isn't caught up in the admit could show the family back, answer brief questions and then give them a time frame for when they can come back and stay for a spell.
When we tell families that they can stay however long they want, even overnight, we're creating an expectation. They believe that the loving thing to do, then, is to stay overnight. If they don't stay overnight they don't love the patient enough. When families expect themselves to stay at the bedside, they often overlook taking care of themselves, skipping meals, delaying bathroom breaks and forgoing sleep. So one of the first things I tell family is that it's OK to go home. When the oxygen masks drop in the aircraft, you put your own mask on first, THEN help others. Family members of critically ill patients need to be encouraged to take care of themselves. It doesn't hurt for the patient's nurse to check in with them . . . did they get enough sleep? Have they eaten? The cafeteria is on the first floor and they serve awfully good salads. (Or ice cream or whatever.) It's OK not to be here every minute because I'll be at the bedside -- they can call me anytime.
Family members who are told that while visiting hours are 24/7, it would be a good idea for them to go home for the night are more likely to actually GO home than family members who are simply told they can stay. I usually tell the families of my fresh post-op patients that "There's nothing you can do for him tonight -- but tomorrow he's going to have to get out of bed to sit in the chair or go for a walk, he's going to need help with his meals and reminders when it's time to cough and deep breathe. That's when you can really help him. So go home and get some rest now, so you'll be fresh in the morning when he needs you." I follow up with a card with the phone number for the unit and the message that they can call any time they feel the need and the nurse will give them an update.
It is helpful if there is someone besides the bedside nurse who can screen visitors -- and usually that falls to the first person they see when entering the unit. If that's a secretary, keep the secretary updated when visiting is going to be a problem. Let them know that "we're putting a line in Mr. Smith, and it will be at least 20 minutes before the family can come back," or "Mr. Jones' family can come back, but I need to talk to them about the isolation procedures first, so call me." If the unit is so poorly designed that the first person they see is likely to be some random staff person running between rooms (and my old ICU was exactly that way), it's far more difficult. If you're that random person they see first, direct them to the front desk, to the patient's nurse or even to the charge nurse or a Clin Tech who can help them -- don't just rush on by unless your patient has just arrested.
Family are more likely to pay attention to a closed door, a drawn curtain or a sign advising them to please come back later if someone has given them a heads up earlier. I try to give the family some expectations for the shift the first time I see them. "We plan to put in a central line sometime today. If you come back to visit and the door is closed or the curtain is drawn, please give us 20 minutes or so, and then come back again." Be sure to give yourself a generous time frame. If you tell the family they can come back in 20 minutes and it takes an hour to finish, they'll be understandably worried.
Most critical care units have some sort of rules for visitors -- ours are posted in the waiting room and spelled out in a brochure visitors are handed the first time they visit. Please follow the rules. If you don't adhere to the rules for visiting, the nurse who follows you and tries to enforce the rules is then the bad guy. It's a poor nurse who sets up her colleagues to be the bad guy, but we see it all the time. Someone just wants to get through their shift with a minimum of discomfort, and so lets the visitors do whatever they want without speaking to them about it. The next nurse is then treated to a struggle and potentially a nastygram from the family to the boss. Don't do it! Just stick to the rules. They can always be relaxed if it's a special case (Grandma is about to die or grandson just got off the plane from his deployment to the middle east), but if you DO relax the rules, make sure you TELL the family that you're relaxing the rules just for right now because it's a special case. Don't create the expectation that it's always going to be a party in the room at 3 AM.