Alberto Giannini

What’s new in ICU visiting policies: can we continue to keep the doors closed?

1 Pediatric Intensive Care Unit Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Via della Commenda 9 20122 Milan, Italy 2 Medical-Surgical Intensive Care Unit Groupe Hospitalièr Paris Saint Joseph 185 rue Raymond Losserand 75014 Paris, France 3 IAME, UMR 1137, INSERM, F-75018 Paris, France IAME, UMR 1137, Paris Diderot University, Sorbonne Paris Cité, F-75018 Paris, France 5 Plymouth University, School of Nursing and Midwifery, Faculty of Health, Education and Society 8 Portland Villas, Drake Circus, Plymouth, PL4 8AA, United Kingdom 6 Curtin University, School of Nursing and Midwifery, Faculty of Health Sciences GPO Box U1987 Curtin University, Perth 6845, Australia 7 Neonatal Intensive Care, Department of Pediatrics Erasmus MC-Sophia Childrens Hospital PO Box 2060 3000 CB Rotterdam, The Netherlands

Parental presence and visiting policies in Italian pediatric intensive care units: A national survey

Objective: To investigate parental presence and visiting policies in Italian pediatric intensive care units (PICUs). Design: Descriptive survey. Setting: All 34 Italian PICUs. Patients: Patients were not involved in this work. Interventions: None. Measurements and Main Results: A questionnaire was sent to the unit heads. Response rate was 100%. Median daily visiting time for parents was 300 mins; for other visitors, it was 120 mins. Twelve percent of PICUs had unrestricted policies; 59% did not allow the constant presence of a parent, even during the day. Visits from other relatives and from nonfamily were not permitted in 35% and 88% of units, respectively. Policies were not modified for a dying patient in 6% of PICUs. Childrens visits were not allowed in 76% of units. Cardiac surgical PICUs were more likely to have restrictive visiting hours. Parents were permitted to be present at the bedside during ordinary nursing procedures, invasive procedures or cardiopulmonary resuscitation in 62%, 3%, and 9% of PICUs, respectively. No waiting room was provided in 32% of PICUs. Gowning procedures were compulsory for visitors in 94% of units. In 48% of PICUs, a formal process of revising visiting policies was ongoing. On patient admission, 77% of PICUs provided the family with informative material on the unit. Phone information on the patient was given frequently (often/always, 70% of PICUs). Conclusions: In Italian PICUs, there is a marked tendency to apply restrictive visiting policies, not to allow parents 24-hr access at bedside, and to limit the presence of parents during procedures and cardiopulmonary resuscitation. A revision of current policies has begun, signaling a readiness for change.

Reduction in catheter-related infections after switching from povidone-iodine to chlorhexidine for the exit-site care of tunneled central venous catheters in children on hemodialysis.

Only a few studies have investigated the optimal exit site management of tunneled central venous catheters (CVCs) in pediatric patients on chronic hemodialysis (HD). The aim of this study was to assess the efficacy of chlorhexidine solutions and a 5% povidone‐iodine solution on the incidence of CVC‐related infections in children on HD. The incidence of exit‐site infection (ESI), tunnel infection (TI), and bloodstream infection (BSI) was assessed in two groups of tunneled CVCs. The iodopovidone group consisted of 14 CVCs used between 1 January 2011 and 30 June 2012 in 10 children, whose median age at the time of CVC placement was 11.8 years (range 1.2–19.2): 5% povidone‐iodine was used for CVC exit‐site care. From 1 August 2012 to 31 January 2014, 0.5% chlorhexidine gluconate/70% isopropyl alcohol was used for the exit site, and 2% chlorhexidine gluconate/70% isopropyl alcohol spray for the hub in 13 CVCs was used in 10 patients (chlorhexidine group), whose median age at the time of CVC placement was 10 years (range 1.2–19.2). Ten episodes of ESI were diagnosed in the iodopovidone group (incidence 3.4/1000 CVC days), and only one in the chlorhexidine group (incidence 0.36/1000 CVC days, P = 0.008). One TI was observed in the iodopovidone group (0.34/1000 CVC days), and none in the chlorhexidine group. The incidence of BSIs decreased from 1.7/1000 CVC days (5 cases) to 0.36/1000 CVC days (1 case, P = 0.06) after switching to chlorhexidine. Two CVCs were lost due to CVC‐related infections in the iodopovidone group, whereas no CVC was lost due to infections in the chlorhexidine group. In comparison with 5% povidone‐iodine, the use of chlorhexidine gluconate was associated with a reduction in the incidence of ESI, TI, and BSI in children on HD.

Andante moderato: signs of change in visiting policies for Italian ICUs

Dear Editor, An association of ex-patients recently conducted a telephone survey [1] regarding visiting time in the same nationwide network of Italian intensive care units (ICUs) that we previously surveyed in 2006 [2]. With the authors’ permission we analyzed their findings, which are posted on their website. The response rate was 88% (369/ 420). We calculated from the findings that daily median visiting time is 115 min (range 10 min to 24 h). Around 2% of units have unrestricted policies, while in 1.4% of ICUs no visiting whatsoever is allowed. By contrast, the 2006 study found that daily median visiting time was 60 min, whereas the percentages of ICUs with 24 h visiting and of those permitting no visits were 0.4% and 2%, respectively. A comparison of these two studies demonstrates that, over the last 5 years, there has been perceptible change in the Italian critical care setting: daily visiting time has essentially doubled, and there has been a substantial increase in ICUs allowing 24 h visiting. This bears out our own finding that a revision of current policies is underway [2], but it is still clear that, overall, Italian ICUs maintain very restrictive visiting policies. Only pediatric ICUs deviate somewhat from this, applying more liberal policies than adult units [3]. It is interesting that the present study was conducted by an expatients association. This emphasizes that such issues are not the exclusive prerogative of physicians and nurses. On the contrary, they matter to the whole of society, which is now asking healthcare professionals mature and carefully considered questions about their behavior and actions, and expects proper answers. If we agree with Burchardi [4], ‘‘opening’’ ICUs constitutes a priority. However, in Italy as elsewhere, there is still not full awareness that the presence of loved ones at the bedside is beneficial for the patient and that in the critical care setting family is actually a resource rather than a hindrance. Creating ‘‘open’’ ICUs is not just a question of time [5], and in countries where restrictive visiting policies persist, at least three issues need to be addressed. Firstly, the information and education of ICU physicians and nurses: time and resources must be invested to increase sensitization to the issues of visiting policies, patient and family needs, and patient-centered ICU. An example is the recent initiative of the Italian Association of Intensive Care Nurses (http://www. aniarti.it), which set up a national training program specifically dedicated to ‘‘opening’’ ICUs. Secondly, communication skills must be designated a specific professional competence for ICU caregivers, to be updated or improved as required. Thirdly, unrestricted visiting should be a condition for a hospital’s national health service accreditation. ‘‘Opening’’ ICUs is a useful and justified choice, which communicates respect and care to those living through the difficult time of illness, and offers an effective response to the needs of patients and families. We believe that the necessary cultural change must be supported and that the time is now ripe for the European Society of Intensive Care Medicine to draw up specific recommendations on this issue.

EMpowerment of PArents in THe Intensive Care Questionnaire: Translation and Validation in Italian PICUs

Objectives: To translate and validate the EMpowerment of PArents in THe Intensive Care questionnaire to measure parent satisfaction and experiences in Italian PICUs. Design: Prospective, multicenter study. Setting: Four medical/surgical Italian PICUs in three tertiary hospitals. Patients: Families of children, 0–16 years old, admitted to the PICUs were invited to participate. Inclusion criteria were PICU length of stay greater than 24 hours and good comprehension of Italian language by parents/guardians. Exclusion criteria were readmission within 6 months and parents of a child who died in the PICU. Interventions: Distribution, at PICU discharge, of the EMpowerment of PArents in THe Intensive Care questionnaire with 65 items divided into five domains and a six-point rating scale: 1 “ certainly no” to 6 “certainly yes.” Measurements and Main Results: Back and forward translations of the EMpowerment of PArents in THe Intensive Care questionnaire between Dutch (original version) and Italian languages were deployed. Cultural adaptation of the instrument was confirmed by a consultation with a representative parent group (n = 10). Totally, 150 of 190 parents (79%) participated in the study. On item level, 12 statements scored a mean below 5.0. The Cronbach’s &agr;, measured for internal consistency, on domain level was between 0.67 and 0.96. Congruent validity was measured by correlating the five domains with four gold standard satisfaction measures and showed adequate correlations (rs, 0.41–0.71; p < 0.05). No significant differences occurred in the nondifferential validity testing between three children’s characteristics and the domains; excepting parents with a child for a surgical and planned admission were more satisfied on information and organization issues. Conclusions: The Italian version of the EMpowerment of PArents in THe Intensive Care questionnaire has satisfactory reliability and validity estimates and seems to be appropriate for Italian PICU setting. It is an important instrument providing benchmark data to be used in the process of quality improvement toward the development of a family-centered care philosophy within Italian PICUs.

Locked‐in–like fulminant infantile Guillain–Barré syndrome associated with herpes simplex virus 1 infection

Guillain–Barré syndrome (GBS) may rarely manifest as a peripheral locked‐in syndrome.

Visiting policies and family presence in ICU: a matter for legislation?

Dear Editor, The Italian Senate Committee on Health recently started examining a bill on the subject of visiting policies and family presence in ICU [1]. In Italy, healthcare is largely in the hands of the regional governments, though parliament retains the power to dictate general policy. The bill in question—a brief document of four articles—stipulates that the introduction of the ‘‘open’’ ICU model [2] constitutes a primary objective of the national health plan; it therefore mandates the Health Ministry and the regional governments to establish norms on five key points. Firstly, recognizing a specific patient right, it states that daily visiting time should be at least 12 h in adult ICUs and without restrictions in neonatal and pediatric ICUs. Secondly, it requires that suitably qualified personnel should be available in ICU to provide appropriate psychological support to the patient and family members. Thirdly, it stipulates the creation of specific training paths for ICU doctors and nurses, with particular attention to communication skills (recognized as an area of professional competency). Fourthly, it sets out that hospital construction plans should be drawn up in such a way as to facilitate the creation of the ‘‘open’’ ICU model of care (incorporating, for instance, areas suitably equipped for family members). Finally, it links National Health Service supplementary funding for the regional governments to implementation of the law, ensuring that to some extent ‘‘open’’ ICU becomes a requirement for a hospital’s accreditation in the Italian National Health Service. That such a bill exists undoubtedly indicates the interest of the whole of society in these issues, which can today no longer be considered an exclusive prerogative of physicians and nurses. However, do we actually need a law on visiting in ICU? Is it right to have legislation on every aspect of medical practice, or should we consider it an unwarranted intrusion? In principle, I believe it is neither useful nor appropriate that legislation should dictate every detail of every aspect of medical activity and hospital life, rather than confining itself to addressing the definition of health policy. We must, however, acknowledge that in some areas parliamentary intervention can be decisive in ‘‘making the leap’’ to achieve higher quality and standardize practice. An example is the recent law passed in Italy governing palliative treatment and pain management [3], stipulating that particular attention be paid to these aspects from both the clinical and the organizational point of view. Italian ICUs today still apply particularly restrictive visiting policies: current daily visiting time is around 2 h with 2 % of ICUs allowing 24 h visiting, while in 1.4 % of units no visiting whatsoever is allowed [4]. Moreover, no waiting room is provided by 25 % of ICUs [5]. Neither the European nor the Italian Societies of Intensive Care Medicine have yet made recommendations about this. However, in my view, they should issue a strong statement of position, acknowledging clearly and unequivocally the importance of these matters to quality of care in ICU, and urging the liberalization of visiting policies. A statement of this kind could reduce the need for parliament to become involved in excessive detail. As things stand, however, a simple ‘‘policy’’ law like the one under consideration could be a useful tool in fostering the necessary cultural and organizational change.

Split catheters in children on chronic hemodialysis: a single-center experience.

Tunneled central venous catheters (CVCs) play an increasing role as vascular access for chronic hemodialysis (HD) in children, but limited data exist about the optimal CVC choice. We analyzed the outcome, efficacy, and complications of tunneled CVCs, placed in our unit in the last 3 years. Nineteen 10 F Split‐Cath CVCs (two separate catheters fused along their length) were placed in 10 children, median age 9.19 years (range 2.15–13.31) and body weight (BW) between 10 and 40 kg. CVCs survival at 1, 3, 6, and 12 months was 94%, 77%, 51%, and 34%, respectively. Catheter survival was higher in children with BW > 20 kg than in smaller patients. Median survival was higher than that of 11 Quinton Permcath CVCs, placed in five children in the preceding 2 years (280 vs. 45 days, P < 0.05). Median blood flow rate and indices of HD adequacy were higher in children with lower BW (<20 kg vs. 20–30 kg vs. >30 kg) than in those with higher BW. Incidence of exit site and bloodstream infections was 2.32 and 0.66/1000 CVC days, respectively. One case of hemothorax due to subclavian artery puncture occurred during CVC placement. In conclusion, Split‐Cath 10 F CVC allows for effective dialysis in children undergoing HD, particularly those between 10 and 30 kg BW. Catheter survival is acceptable, but could be improved in small children.

Parental presence in Italian pediatric intensive care units: a reappraisal of current visiting policies

Dear Editor, In 2007 a national survey found a clear tendency in Italian pediatric intensive care units (PICUs) to apply restrictive visiting policies and to limit parental presence at the bedside [1]. In order to update our picture on current parental presence and visiting polices in Italian PICUs and assess the possible impact of the recent position statement on this topic by the Italian National Committee for Bioethics (INCB) [2], we carried out a fresh nationwide survey. A questionnaire was sent to all 30 Italian PICUs. Response rate was 100%. Median daily visiting time was 8 h for parents and 2 h for other visitors. Only 23% of PICUs had a 24-h visiting policy; 59% of units did not allow the constant presence of a parent even during the day. Just 7% of units permitted parental presence during invasive procedures and cardiopulmonary resuscitation; for ordinary nursing procedures it was allowed in 70% of them. Moreover, parental presence at the patient’s bedside during doctors’ visits, attendance at clinical rounds, and nurses’ handovers (allowed in 33, 14, and 7% of units, respectively) represented more the exception than the rule. Children can visit in only 37% of PICUs. A gowning procedure was still compulsory for visitors in most (70%) units. Units with a lower nurse/patient ratio and cardiac surgery units had more restricted visiting hours for parents. Daily meetings of doctors with parents were held systematically in almost all PICUs (97%) and were mainly conducted by the physician on duty (79%) and/ or unit head (21%). Nearly half the units revised their visiting policy in the last 5 years and in 43% of PICUs a process of revision of the ward’s visiting policies was underway. The snapshot that this study provides has both good and bad news. On the one hand, despite authoritative recommendations [2] Italian PICUs today still have essentially restrictive visiting policies. On the other hand, many units have moved on and currently have on the whole more “liberal” policies than those of 9 years ago (Table 1) and those of Italian adult ICUs [3]. Although organizational factors may play a part (e.g., understaffing of nurses), we believe that the concept of the family-centered ICU [4, 5] has yet to make a breakthrough. Moreover, the INCB recommendations have yet to be fully taken in. On the subject of visiting policies in PICUs there are no national surveys from other countries and the recent literature offers no substantial data for comparison purposes. We can conjecture that, in contrast to the findings in Italy, in most European and North American countries parental presence and a 24-h visiting policy are now widely established and are no longer a question for debate.

The “Open” Intensive Care Unit: the Challenge Continues

Nearly 10 years have passed since Hilmar Burchardi, past president of the European Society of Intensive Care Medicine, wrote in an editorial in Intensive Care Medicine that “it is time to acknowledge that the ICU must be a place where humanity has a high priority. It is time to open those ICUs which are still closed [1]”.