Ethical & Vulnerable

Population: Patients with

COVID-19 in the ICU
By: Angela Acuna, Lynda Attalah, Quincy Eastlack,
Gabrielle Haugen, Jack Hauser, Katya Kirkland,
Neela Minesinger, Whitley Orvik, & Mariah
Vasquez-Gilvin
Introduction

Since the COVID-19 pandemic, family

visitation at hospitals have drastically
decreased to reduce the spread of infection.
98% of ICUs had a ‘‘no visitor” policy.
[Joan Wong]/[NBC News ] via Getty Images
Complication of visitor restrictions include but
are not limited to:
● Difficulties with updating families on
patient care
● Family and patient distress increase
● Lack of updates for non-english speakers
● Traumatizing experience for both patient
and families (Wendlandt et al., 2021)
Introduction cont.

Many factors make it difficult for

hospital’s to provide alternatives to
visitation. Most common reasons
include:
○ Limited access to technology
& devices (58%)
○ Lack of knowledge Milad Hospital During COVID-19 Pandemic. (Bazargard, 2020).

surrounding technology (55%)

○ Lack of integration with EMR
(41%)
(Mohammed et al., 2020)
Introduction cont.
Technology based communication during COVID-19
This is not a perfected process and includes some downside such as:
- Distracting from patient care
- Very time consuming
- Technical difficulties
- Requires added resources and training
Physician VS Nursing opinions on family visitation restriction
- Improved workflow
- Direct focus on patient care (Annenberg Foundation , 2020)

- Emotional support shift from Nursing to Physicians

- Burn-out / Job-related stress
(Wendlandt et al., 2021)
PICOT Question

In patients diagnosed with COVID-19, does the use of virtual family

and friend visitations, compared to no virtual visitations, due to lack
of provisions, improve physical and mental well-being by reducing
levels of patient and family anxiety, and improving perceived quality
of care during their ICU hospital stay?

What is the best clinical practice regarding visitation protocols for

isolated patients with COVID-19?
Current Practice
What is being done locally for COVID ICU patients ?

TMC Policies Carondelet Health

● Window visitations allowed (COVID
only)
● Family switch outs allowed
● Virtual visitation
Banner Visitor Policies
● COVID patients allowed one visitor
MAX
● PPE required for visitors in patient
room
● No switch outs allowed
● No visitors allowed for COVID-19
positive patients
● Exceptions made for end-of-life
needs through window visitation
Northwest Visitor Policies
● One visitor allowed non COVID
● NO visitors allowed for COVID ICU
 Current Practice cont.

Overall national restrictions

● Most hospitals allow one visitor only

● Full PPE use and precautions
● Tablet use for virtual communication
● Strict time frame for visitation hours

(Seton, n.d.)

(Wendlandt et al., 2021)

 Support for Virtual Visitation

● Decreased levels of anxiety experienced

by patients and their families
● Improved family experience and patient
quality of care
● Reduce psychological stressors and
improved patient outcomes
● Improved staff morale and patient
recovery
(Haruna et al., 2021; Rose et al., 2021; Wendlandt et al., 2022)

(Gavin, 2020)
Support for Virtual Visitation

● Decreased depression and anxiety experienced by families post-discharge

● Allowed for significant events (i.e., birthdays, anniversaries, etc.) to be
acknowledged → appreciation from patients and families
● Provided means of communication between healthcare team and family →
holistic patient-centered planning
● Positive changes to daily workflow for nurses - increased time and physical
space to provide care in the absence of visitors

(Kebapçı & Türkmen, 2021; Rose et al., 2021; Wendlandt et al., 2022)
Strengths & Limitations

Strengths
○ Cost-effectiveness (Downar & Kekewich, 2021)
■ Little resources needed to conduct surveys and interviews
○ Versatility
■ Insight into valuable creation
○ Reliability
■ Qualitative, cross-sectional, & quantitative studies
○ Generalizability
■ Studies done in: US, UK, Netherlands, Canada (Kebapci & Turkmen, 2021; Maaskant et al., 2021;
Mohammed et al., 2021; Rose et al., 2021;
Sasangohar et al., 2021’; Wendlandt et al., 2022)
Strengths & Limitations

Limitations
○ Cost-effectiveness
■ Time of hospital staff
○ Versatility (Matsos, 2020)

■ Surging deaths of COVID-19 increased anxiety

○ Reliability
■ Interviews of family members were done by hospital staff
■ Reviewed just during the pandemic
○ Generalizability
(Kebapci & Turkmen, 2021; Maaskant
■ Lack of family access or understanding technology et al., 2021; Mohammed et al., 2021;
■ Findings may not be generalizable to all countries Rose et al., 2021; Sasangohar et al.,
2021; Wendlandt et al., 2022)
Evidence-Based Nursing Practice Recommendation

The best practice during times of restricted in-person visitations would be virtual
communication via HIPAA compliant video chat software to increase patient
health outcomes, decrease levels of anxiety, as well as increase satisfaction with
care by both the family and patient.

(Heyward & Wood, 2020)

Application & Implementation

● Meet with nursing leadership

● Acquire enough iPads for each ICU bed and Doxy.me software to conduct video
calls (Doxy.me, n.d.)
● Create information pamphlets to give to families on virtual visitation. These
pamphlets will contain:
○ How to turn on iPad and access the camera.
○ A QR code that directs the device to a particular meeting link.
○ How to join and leave the meeting.
● Train interdisciplinary staff
Patient Satisfaction Survey

● Patients who utilize the virtual visitation system will be asked to answer a
survey to assess levels of psychological distress and perception on quality
of care.
○ Utilize the hospital anxiety-depression scale (HADS) to quantify levels of anxiety in
hospitalized patients.
○ Include questions that assess overall satisfaction, ease of usage, staff engagement, and any
suggestions for improvement.
● Compare values to pre-implementation to evaluate effectiveness of
intervention.

(Kebapci & Türkmen, 2021)

Application & Implementation: Timeline

● 4 weeks to acquire devices and install software

● 3 weeks to train staff on iPad/software usage
○ During these 7 weeks of set-up, surveys are already being conducted in order to establish a
control group of patients who did not have the option of virtual visitation
● 1 week to set up iPads in patient rooms and prepare pamphlets for
distribution
● 3 month trial period with surveys for each patient and family who used the
virtual visitation
● 2 months to analyze data and effectiveness of virtual visits
Cost Analysis

Software- Doxy.me
● HIPAA compliant
● No download required
● Free
● Accessible on desktop, tablet or smartphone
● Easiest telemedicine solution (Doxy.me, n.d.)

Internet
● Need 1,000 mbps
● Each iPad uses 200 mb/hour for FaceTime (Wright, 2018).
(Doxy.me, n.d.)

Electricity
● 12.kWh/year= $1.50 x 20= $30/year (Smith, 2016)
Cost Analysis
Hardware

● Mobile Device
(Multiple Devices. n.d.)
○ Cell Phone plan: $113/month (patient’s family)
○ Average price of a cell phone: $363 (patient’s family) (Lake, 2022)
● Tablet vs iPad for the hospital?
○ Apple iOS is better than Android operating system (Franklin, 2020)
○ Cost:
■ $349 x 20 (# of beds in ICU)= $6,980 (Apple, n.d.)
● Joy Factory aXtion Pro MPA Antimicrobial Healthcare Case (Amazon.com. n.d.)
○ $189.99 x 20= $3,799.80
■ Waterproof, Shockproof, Built-in screen protector
■ C-Clamp to attach to a hospital bed
■ Easy cleaning and sanitizing (Amazon.com. n.d.)
● iPad Charging Station
○ $67.99 x 2= $135.98 (Amazon.com. n.d.)
Cost Analysis
IT Staff for training
● $63,742/year Salary (Indeed.com, 2022)
● 1-4 hours a month = $33.20 - $132.80/month = $398.40 - $1,593.60/year
Nurses & Chaplains
● 1-2 nurses/week
● 2 Chaplains- $23/hr
● 3-6 hours per day time commitment (Pickell et al., 2020)
Pamphlets and flyers to inform patients in ICU
● Qty 1000: $299.99 of pamphlets
● Qty 250: $119.99 of flyers (Staples.com, n.d.)
Risks Associated with Virtual Visitations

Institution
● Connectivity - especially, in rural areas
● Cost/resources - hardware, software, staff
Nursing Staff
● Staff availability for facilitating virtual visits
● Dissatisfaction & increased workload
Patient & Family
● Varying levels of technological literacy
● Barriers for those with visual or auditory impairments
● Confidentiality - PHI protection within the software
(Ersek et al., 2021; Maaskant et al., 2021)
 Benefits of Virtual Visitations
Institution
● Alternative means of communication with families
● Improved patient and family satisfaction
Nursing Staff (Young & McMahon, 2020)

● More holistic approach to patient-centered care in the midst of visitor restrictions

● Structured vistitations (i.e., designated times, less people in room)
Patient
● Improvement of overall health
● Reduced levels of anxiety for patients and their families
● Familial involvement in the absence of physical presence
Evaluation: SMART Patient Outcomes

● Patient will be given the option to communicate at least once a day to their
families via a mobile device provided by the hospital.
○ Chart when virtual visits are offered to evaluate
■ I.e., “Patient/family participated in virtual visit.” or “Patient/family refused
virtual visitation at this time.”

● Patients will report a decreased anxiety score by at least 2 points on average

on the HADS scale after having a virtual visit with their family or friends.

● By the end of hospitalization, at least one in every two patients who utilize
virtual visitation will report being satisfied with their quality of care in the
post-care survey.
Summary & Final Thoughts

● The pandemic forced healthcare facilities to change their practices and

protocols
● How can we consider the whole patient in the midst of visitation
restrictions?
● VIRTUAL VISITATIONS
○ Reduced levels of anxiety and depression
○ Improved levels of perceived quality of care
○ Familial involvement → holistic, inclusive, patient-centered care
● Do the risks and costs outweigh the benefits?
● Future Research: effects on delirium and length of stay
QUESTIONS?
Thank you!
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