Intensive Care Gets Friendlier with Apps, Devices

Hospitals are redesigning intensive care units to make them safer and less dehumanizing, with a new focus on engaging families and patients in decisions.

ICU teams are testing novel approaches to solicit input from patients and their families, and to honor their preferences and goals for care. Many are using apps and devices to link up medical teams with families. Evidence has shown that patient and family participation can improve safety and outcomes, and hospitals are putting a failure to treat patients with respect and dignity on a par with other preventable medical complications.

“We are broadening the definition of harm to include disrespectful care, which is every bit as important as an infection in the ICU,” saysPeter Pronovost, a critical care physician and director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine in Baltimore, one of four centers whose top patient safety experts are working on ICU redesign projects funded by the nonprofit Gordon and Betty Moore Foundation.

More than five million Americans a year are treated in an ICU, where they face the highest risks of complications such as infections, blood clots, and pneumonia. Hooked up to machines, they also suffer a loss of privacy, autonomy and control. Despite more liberal visitation policies in recent years, ICUs have been slow to include patients and their families in decisions, in part because of concerns they might interfere with nurses and doctors as they treat dire medical conditions.

At Johns Hopkins, Project Emerge is gathering data from records systems and monitoring equipment, and integrating it into an electronic “harms monitor” for the surgical ICU. By tracking tasks that need to be done, it reminds staff members when to perform preventive measures for complications. It alerts them to situations when their patients may be at risk, such as over-sedation that can lead to severe confusion and hallucinations and harm mental function in the long-term. Red indicates an urgent action needs to take place, yellow indicates a task to prevent harm needs to occur soon and green signals everything is completed.

Dr. Pronovost’s studies have shown, for example, that bloodstream infections linked to catheters can be reduced by 66% with a checklist of preventive steps, but those steps aren’t always followed. The monitor would also link staffers to reminders of the steps and treatments to prevent harm.

In addition to five medical complications, the project aims to track “respect and dignity” and “goals of care” to indicate whether the team is considering patient and family preferences. Hopkins is providing patients and families with their own tablet devices to record their care goals, ask questions of the medical team, and learn about machines and monitors in their room. A family involvement app lets them select daily activities they want to assist the staff with such as washing the patient’s hair, or helping them get out of bed and walk. ICU teams are expected to regularly discuss and update goals with patients and families.

While tracking risks of blood clots or infections is straightforward, to identify and rectify a lack of respect and dignity is “more complicated,” saysRhonda Wyskiel, a nurse researcher on the project. Hopkins’ Berman Institute of Bioethics is developing measurement methods using surveys of patients and families to identify problems. Ms. Wyskiel says they could include a family meeting that wasn’t scheduled when key decisions needed to be made, neglecting to close a privacy curtain when pulling up a patient’s gown or failing to introduce staffers when they enter the patient’s room. Staffers are being trained to watch for such issues.

Brigham and Women’s Hospital in Boston developed a web-based portal on a bedside device, called the Patient-Centered Toolkit, where patients and families in the ICU and adult oncology units can access the plan of care and get links to health information about their condition, medications and lab results. The device also lets them pose questions to the team, says David Bates, Brigham’s chief innovation officer and principal investigator for the principal investigator for the project known as Prospect, for Promoting Respect and Ongoing Safety through Patient-Centeredness, Engagement, Communication and Technology.

Dr. Bates acknowledges it has taken “a lot of cheerleading” to get ICU teams comfortable with the idea. And conflicts can arise if, for example, families want to be more aggressive with care than is possible. Designating a nurse to act as spokesperson for the team usually helps resolve the situation, he says.

Bruce Haggarty, 49, was in Brigham’s medical ICU for 2½ weeks with complications from cystic fibrosis, before having a lung transplant in February. A breathing tube and restrictions on drinking made his throat dry. When his wife Deb Rivkin went through his medications list, she saw the staff was still providing the allergy medication he used outside the hospital. Because such medications can add to dryness, she alerted one of the doctors, who agreed it would be fine to stop it while he was in the ICU. She also checked his lab results and sent a screenshot to his regular doctor.

Ms. Rivkin says that in general, she felt she and her husband were heard and treated with respect, even when the ICU team prevailed. For example, Ms. Rivkin was worried that a medication given to help him sleep was giving him nightmares, but says nurses were “pretty adamant” that he needed it to sleep, “so I had to trust that.” Following his transplant on Feb. 13, he is recovering in another unit.

At the University of California, San Francisco, which is adopting the Hopkins model, Michael A. Gropper, a professor and interim chair of the Department of Anesthesia and Perioperative Care, says patients can easily have 20 different clinicians treating them in a day, so their tablets are loaded with descriptions identifying them and their area of expertise.

“There are so many patients on life support, and ventilators, and there are IVs and bags everywhere and you just don’t feel as if you have any control,” says Michelle Young, a UCSF advisory council member who provided feedback on the project. Her daughter, Amberle, was in and out of the ICU over several years struggling with a number of autoimmune disorders, and died of complications from an infection in 2013 at age 23. “Patients need more transparency and access and education on how to navigate the ICU,” Ms. Young says.

Beth Israel Deaconess Medical Center in Boston, which is developing its own technology to provide a real-time snapshot of risks developing in its intensive care unit, is providing a portal for patients and families called MyICU. The hospital consulted with patients and families on its critical care advisory committee on priorities and got some unexpected feedback. “While we assumed that beeping and noise from machines would be a big distraction, they talked more about being approached and touched without adequate explanation,” says Kenneth Sands, senior vice president of health care quality at the hospital. Some also cited a lack of respect for personal valuables.

Dr. Sands says: “If we lose your wedding ring while you are in the hospital, you would consider that a long-lasting harm.”

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