Running head: INTEGRATIVE REVIEW 1

Integrative Review

Bianca Morales

Karen Mellott, PhD, RN

NUR 4322: Nursing Research

Bon Secours Memorial College of Nursing

April 9, 2020

“I pledge”
INTEGRATIVE REVIEW 2

Abstract

Purpose: The purpose of this integrative review is to identify if there is a relationship between

family visitation and the incidence of the delirium in adult patients in the Intensive Care Unit.

Introduction and Background: Delirium is a prevalent problem that occurs in many critically

ill patients that can extend their stay in the ICU; common issues include long-term neurological

complications and an increase in mortality. Studies have shown that family-centered care

interventions could possibly decrease delirium and improve patient and family outcomes.

Design and Search Methods: This is an integrative review in which research was collected

from online databases. The articles discussed are quantitative and qualitative studies, and each

were chosen based on specific criteria. This information was used to discuss and determine the

effects of flexible visitation hours and the incidence of delirium.

Results and Findings: The findings suggest and support the evidence that extended visitation

hours for family can decrease the incidence of delirium in the Intensive Care Unit.

Limitations: The most significant limitation is the author’s inexperience in conducting an

integrative review.

Implications: The implementation of an extended visitation model in critical care units has been

shown improve patient outcomes and have shown to increase family satisfaction.

Recommendations: It is a recommendation that further study be conducted to increase the value

and credibility of the findings. The focus should be on more structured interaction and education

of the families in the effort for prevention.

INTEGRATIVE REVIEW 3

Integrative Review

The purpose of this integrate review is to identify the effect of family visitation on the

incidence of delirium in patients that are critically ill. Throughout the world, patients that are

admitted into an Intensive Care Unit (ICU) are often limited by time spent with family and

visitors. Restricted visiting hours are often policies that are currently held in many ICUs that

increase physiological stress, infectious complications and result in a possible deviation of care

(Rosa et al., 2018). Research has helped develop theories reveal possible interventions that may

lead to delirium prevention. A prevalent theory that has developed is flexible family visitation as

a method of prevention for ICU delirium. ICU delirium is defined as an acute mental disturbance

that causes a patient to have decreased awareness of surroundings, confusion and many other

neurological complications (Smithburger etal., 2017). Delirium in the ICU poses an increased

risk to patients that can result in long-term compilations, longer hospital stays and an increase in

mortality rate (Smithburger et al., 2017). The aim of this review is to examine and discuss

previous research as it relates to the researcher’s PICO question: In critically ill patients at risk

for delirium, how does the implementation of extended family visitation effect the incidence of

delirium in patients that are in the ICU, compared to patients with restricted family visitation

during the time of hospitalization?

Design/Search Methods

The research design is an integrative review. The articles were researched using two

search engines, OvidDS and PubMed databases. The search words were delirium, Intensive Care

Unit, family visitation, family outcomes, prevention, delirium prevention, adults, and incidence.

The results yielded over 7,000 articles. The articles were filtered by year, study design, language,

scholarly articles, and relevance to the PICOT question. The date of article publication was
INTEGRATIVE REVIEW 4

limited to the years 2012-2020 and only included those that were published and peer-reviewed to

ensure adherence to literature review guidelines. All articles were screened to included all

aspects of the researchers PICOT question. In addition, the articles must have been well-written,

and ethically approved. A total of five articles were chosen after limits to the search process were

applied; these five studies are identified and reference throughout this integrative literature

review. This resulted in one qualitative study and four quantitative studies. Exclusion criteria

included articles that did not include critically ill patients, delirium in the ICU, or the effect of

flexible visitation.

Findings and Results

The results and findings show a decrease in ICU delirium with flexible visitation models

(Rosa et al., 2019; Eghbali-babadi et al., 2017; Smithburger et al., 2017; Rosa et al., 2017; and

Martinez., 2012). A summary of the five research articles is located in Appendix. The following

is a brief overview of each articles’ findings. This review is structured based on the following

themes found among patients that were in Intensive Care Units at risk for delirium: increased

family visitation, and family outcomes

Increased Family Visitation

Four of the five studies showed that there was a significant correlation between the

incidence of delirium and increased family visitation (Rosa et al., 2017; Eghbali-babadi et al.,

2017; Westphal et al., 2018; and Martinez., 2012). Increased family visitation differs in duration

in each article but is collectively defined as an increase in visitation compared to the standard

care or no family visitation at all. In a study conducted by Rosa et al. (2017), the authors aimed

to determine the effect of an extended visitation model compared with a restricted visitation

model and the incidence of delirium in ICU patients. The design of study was a prospective
INTEGRATIVE REVIEW 5

single-center before and after study. The study consisted of 286 patients in a 31-bed tertiary

medical-surgical ICU in Brazil. Patients that were older or equal to 18 years of age and an

expected length of stay longer than 24 hours were enrolled. The data was collected in three

periods. The first period consisted of 90 days with restricted visitation, followed by a second

period of 30 days without patient enrollment. The third period consisted of 90 days with the

extended visitation model. Data analytic methods such as Fisher exact, chi-squared, Wilcoxon

rank-sum, and Student t-test were applied to determine possible outcomes. A significance level

of 0.05 was applied for all comparisons. These tests were appropriate given the data. The

incidence of delirium in the extended visitation was 9.6% compared to the incidence of delirium

in the restricted visitation which was 20.5%. The extended visitation model was found to show

lower occurrences of delirium, shorter ICU stay and shorter length of delirium.

Eghbali-babadi et al. (2017) completed a quantitative study that studies the effect of

family visitation as an important intervention to decrease the incidence of delirium in a critical

care unit in Iran. The type of study design was a randomized controlled clinical trail that

consisted of 68 patients, divided evenly into a control group and an intervention group (Eghbali-

babadi et al., 2017). The patients were between the ages of 18-70 years, were admitted to the

Cardiac ICU and had immediate family available. Patients who met criteria, were randomly

selected into each group. The study consisted of a two-section questionnaire that consisted of the

patient’s demographics and the Confusion Assessment Method –ICU to assess delirium in

participants (Eghbali-babadi et al., 2017). The intervention group consisted of 30- 40 minute

structured and regular visits from a family member who received education about reorientation

techniques. (Eghbali-babadi et al., 2017). Those in the control group received routine care. Data

was analyzed through the Statistical Pack for the Social Sciences version 20 (SPSS 20, Chicago,
INTEGRATIVE REVIEW 6

IL), and by frequency distribution, mean and standard deviation (Eghbali-babadi et al., 2017).

Inferential statistics used were Chi-square, Mann-Whitney, independent t-test and Fisher’s exact

test (Eghbali-babadi et al., 2017). These tests are all appropriate given the data.

In this study, researchers Westphal et al. (2018) aimed to evaluate the significance of a

24-hour extended visiting policy on the incidence of delirium in the ICU. This is a before- after

study that was conducted in Brazil. 248 patients were enrolled in phase one of the study and 268

patients were enrolled in phase two; phase one consisted of family members choosing between

visiting up to 6 hours or the standard protocol of visiting for four half-hour visits. Family

members in phase two could chose an extended 24-hour visitation model or continue with the

standard protocol (Westphal et al., 2018). Data was analyzed with Student’s t test or Mann-

Whitney test to compare the variables; additionally, the Chi-squared test was used for categorical

variables and Poisson regression was used for incidence densities (Westphal et al., 2018). The

incidence of delirium decreased from 12.1% to 6.7% in phase two of the research where family

visitation was allowed 24 hours of the day (Westphal et al., 2018). This research correlates and

increases the validity of the positive effect of increased family visitation hours on the incidence

of delirium. This study differed in that it was the only study had the option of 24-hour visitation

in the ICU.

Lastly, in the study done by Martinez et al. (2012), the authors seek to assess the benefit

of using a multicomponent intervention strategy that may prevent delirium. A total of 287

patients were enrolled who were at risk for developing delirium; these patients were older adults

at the Hospital Naval Almirante Nef in Chile. Patients at risk were determined by a clinical

prediction rule and were divided into groups that received non-pharmacological intervention

delivered by family members or the standard management (Martinez et al., 2012). Data was
INTEGRATIVE REVIEW 7

collected by three observers using the confusion assessment method screening instrument and the

study design used was the prophylactic environmental management of the in-hospital delirium

(PEMID) (Martinez et al., 2012). This is a randomized controlled clinical trial. This study shows

the significance in the intervention that was delivered by the family members compared to the

standard management. The non-pharmacological intervention that was performed by family

members included education, provision of a clock, limited sensory deprivation, reorientation of

patient, and extended visitation time (Martinez et al., 2012). The Fisher’s exact test, Mann–

Whiteny and Students t-test were used; these were tested by the Kolmogorov-Smirnov and

Levene test respectively (Martinez et al., 2012). The incidence of delirium was 5.6% in the

intervention group and 13.3% in the control group (Martinez et al., 2012). Similar to the other

three studies, this article stresses the importance of increased family visitation on the incidence

of delirium, but varies from the others as it explores additional interventions that are carried out

by family members. Additionally, this article only included the older adult population in contrast

to the three other studies.

Family Outcomes

In two of the five articles, the correlation of extended visitation hours on family outcomes

is explored (Rosa et al., 2019 & Smithburger et al., 2017). Family outcomes are determined by

reported feelings of anxiety, depression and satisfaction levels in family members (Rosa et al.,

2019). In a study conducted by Rosa et al. (2019), the authors researched the effect of flexible

family visitation on delirium among patients, family members and ICU staff (Rosa et al., 2019).

The study was a cluster-crossover randomized clinical trial that involved 36 ICUs with restricted

visiting hours in Brazil. 1685 patients, 1295 family members, and 826 clinicians were reenrolled

in the study (Rosa et al., 2019). The study collected data on the incidence of delirium during
INTEGRATIVE REVIEW 8

ICU stay, ICU –acquired infections, anxiety and depression for family members and burnout for

ICU staff. The bonferroni correction was applied to subgroups, and a 2-sided P valued less than .

05 was used as the level of significance for all comparisons (Rosa et al., 2019). The results did

not find a statistical difference between extended visitation and restricted visitation hours and the

incidence of delirium. It did however find that in the families that participated in the extended

visitation hours, had improved family outcomes where anxiety and depression were significantly

decreased. Family satisfaction was also found to be higher in families that participated in the

flexible visitation model. The results were assessed using the Hospital Anxiety and Depression

Scale and family satisfaction was measured using the Critical Care Family Needs Inventory

scale. The incidence was compared at 13.4% vs 28.2% for probable clinical anxiety in flexible

and restricted hours respectively (Rosa et al., 2019). The CCFNI scale showed significant results

for mean satisfaction as 31.5% for flexible visitation vs 27.5% for restricted visitation. The

results indicate family outcomes improve with flexible visitation hours in Intensive Care Units.

In the second study done by Smithburger et al., 2017, a qualitative study was performed

on the perceptions of families in the Intensive Care Unit regarding their involvement in the

prevention of delirium. The study aimed to gather information on recommendations for families

regarding delirium prevention activities that involve the family. The study was performed in a

24-bed medical ICU at an academic medical center (Smithburger et al., 2017). Family members

were interviewed and an interview guide was followed; these interviews were recorded, and

transcribed and then coded by two independent coders (Smithburger et al., 2017). 45 interviews

were conducted and 10 interviews were chosen by purposeful sampling before saturation

occurred (Smithburger et al., 2017). Phrases and sentences were assigned codes, where the coded

phrases were organized into categories and used to identify major themes. Three themes emerged
INTEGRATIVE REVIEW 9

that were important to the families. The grounded theory method was used for the exploratory

nature of the study. This study showcased the importance of family involvement and its effect on

family satisfaction and consequentially, family outcomes. The three themes that developed as a

result of the study, help guide researchers, medical providers and nurses on topics that are

important to family members to promote better family outcomes for those dealing with delirium

in the critically ill.

Discussion/Implications

The articles selected for this review offer insight into the effect of the the highlighted

themes and the incidence of delirium. The PICO question, in critically ill patients at risk for

delirium, how does the implementation of family visitation affect the incidence of delirium in

patients that are in the ICU, compared to patients with no family visitations during the time of

hospitalization was clarified based on the research findings. The studies conducted by (Rosa et

al., 2019; Eghbali-babadi et al., 2017; Smithburger et al., 2017; Rosa et al., 2017; and Martinez.,

2012) highlight the different components of family interaction and the incidence of delirium.

Family interventions and family outcomes were found to be predominant links in adult patients

in the ICU at a risk for delirium. Significant research is needed to add value to the topic of

flexible visitation models and the effect it has on delirium. The research implicates that these

family interventions can improve patient outcomes. Many factors effect delirium and family

intervention is multifaceted. These should be assessed and reexamined in the cases where

delirium is an increased risk to the patient. There are several recommendations that are important

to the nature of this study that include studying the direct correlation of family’s perception of

care, education to families on preventing delirium, and nursing interventions that could possibly

reduce the incidence of delirium.

INTEGRATIVE REVIEW 10

Limitations

In research, limitations are always found and must be included in an integrative review.

The inexperience of the researcher in conducting an integrative review is to noted. In addition,

only five articles were used for the review and due to this, is not exhaustive in nature. The

articles used were within the last eight years, which limits the generalizability of the PICOT

question.

A limitation that was noted by the researcher was in regard to the definition and time of

the extended visitation model. The five articles (Rosa et al., 2019; Eghbali-babadi et al., 2017;

Smithburger et al., 2017; Rosa et al., 2017; and Martinez., 2012) all differ in defining the time

frame of extended visitation. This poses a severe limitation of the study, as the optimal time

frame for extended visitation cannot be determined based on the articles. A second limitation that

was identified was that all five studies (Rosa et al., 2019; Eghbali-babadi et al., 2017;

Smithburger et al., 2017; Rosa et al., 2017; and Martinez., 2012) were conducted in developing

countries where extended visitation hours in the Intensive Care Unit can have different impacts

on differing socioeconomic status, countries, or region cultures.

Conclusion

The evidence complied for this integrative review supports the notion that extended

visitation hours can decrease the incidence of ICU delirium in patients that are critically ill (Rosa

et al., 2019; Eghbali-babadi et al., 2017; Smithburger et al., 2017; Rosa et al., 2017; and

Martinez., 2012). This is directly related to the themes of increased family visitation and family

outcomes. Family-centered care is essential in caring for those patients that are critically ill and

can help improve patient and family outcomes. Loosening restrictive visitation policies and

involving families in the care of patients can significantly make a difference in patient’s
INTEGRATIVE REVIEW 11

incidence of delirium. In relation to the PICOT question being addressed, on the effect of family

visitation and the effect on ICU delirium, the literature reflects a decreased in incidence when

extended family visitation hours are applied critical care units.

INTEGRATIVE REVIEW 12

References

Rosa, R. G., Tonietto, T. F., da Silva, D. B., Gutierres, F. A., Ascoli, A. M., Madeira, L. C., …

Teixeira, C. (2017). Effectiveness and safety of an extended ICU visitation model for

delirium prevention. Critical Care Medicine, 45(10), 1660–1667. Retrieved from: doi:

10.1097/ccm.0000000000002588

Rosa, R. G., Falavigna, M., da Silva, D. B.., Sganzerla, D., Siqueira Santos, M. M., Kochhann,

R., … Teixeira, C. (2019). Effect of flexible family visitation on delirium among patients

in the intensive care unit. Journal of the American Medical Association, 322(3), 216–228.

Retrieved from: doi: 10.1001/jama.2019.8766

Martinez, F. T., Tobar, C., Beddings, C. I., Vallejo, G., & Fuentes, P. (2012). Preventing

delirium in an acute hospital using a non-pharmacological intervention. Age and Ageing,

41(5), 629–634. Retrieved from: doi: 10.1093/ageing/afs060

Mehrabi, T., Eghbali-Babadi, M., & Shokrollahi, N. (2017). Effect of family–patient

communication on the incidence of delirium in hospitalized patients in cardiovascular

surgery ICU. Iranian Journal of Nursing and Midwifery Research, 22(4), 327–331.

Retrieved from: doi: 10.4103/1735-9066.212985

Smithburger, P. L., Korenoski, A. S., Alexander, S. A., & Kane-Gill, S. L. (2017). Perceptions of

families of intensive care unit patients regarding involvement in delirium-prevention

activities: A qualitative study. Critical Care Nurse, 37(6), e1–e9. Retrieved from: doi:

10.4037/ccn2017485
INTEGRATIVE LITERATURE REVIEW 12

APA Citation Author  APA citation: Mehrabi, T., Eghbali-Babadi, M., & Shokrollahi, N. (2017).
Qualifications Effect of family–patient communication on the incidence of delirium in
hospitalized patients in cardiovascular surgery ICU. Iranian Journal of
Nursing and Midwifery Research, 22(4), 327–331. Retrieved from: doi:
10.4103/1735-9066.212985
 Maryam Eghbali-Babadi – Professor at the School of Nursing and midwifery
at Isfahan University of Medical Sciences in Isfahan, Iran.
Background/Problem  Cardiovascular disease are the most important causes of morbidity and
Statement mortality in the world, and cardiac surgery is one of the treatments that have
complication for patients. One of the most important current psychological
complication after cardiac surgery is delirium. For its prevention and
treatment, considerable attention should be paid to the role of family. The
study was conducted for assessing the effect of the relationship between the
family and patient on the incidence of delirium in hospitalized patient in
cardiovascular surgery intensive care unit (ICU).

Conceptual/theoretica  None
l Framework

Design/  Randomized controlled clinical trial

Method/Philosophical
Underpinnings

Sample/  Two-group, single-blind clinical trial that was conducted among 68 patients in
Setting/Ethical the cardiac surgery ICU of Shahid Chamran hospital affiliated to the Isfahan
Considerations University of Medical Science.
 Sample size was 34 subjects per group
 18-70 years’ old
 Patient who met the inclusion criteria were selected through convenient
sampling using a random number table, and were assigned into two groups of
study and control. P1 and P2 were the incidence of delirium in patients, with
INTEGRATIVE REVIEW 13

or without a family visit.

 The ethics committee of the Isfahan University of Medical Sciences approved
this study.
 Informed consent was completed by patients and their families
Major Variables  Age
Studied (and their  Length of surgery
definition), if  Distribution of patient’s demographic characteristics in two groups
appropriate  Relative frequencies of delirium in two group on the second and third days
postsurgery
 Relative frequencies of delirium in two groups on the first, the second, and
the third times
Measurement  Two-section questionnaire
Tool/Data Collection  The first section included subjects’ and family members’ demographic
Method information such as age, sex, education level, occupational status, marital
status, and patient’s vital signs, and surgery-related information
 The second section was a tool to investigate delirium including the CAM-ICU
method, to assess the patient concern delirium.
 Sensitivity and specificity of this scale were reported to be over 90-95%
 Convenient sampling and the patients were allocated to two groups (n = 34
patients) based on random number table.
 Two groups were assessed for delirium twice a day for a total of three times
(two times in the morning and one time in the evening) with use of Richmond
Data Analysis  Statistical package for Social Sciences version 20 and by descriptive
statistical tests such as frequency distribution and distribution, mean and SD,
and inferential statistics (Chi-square, Mann–Whiteney, independent t-test and
Fisher’s exact test.

Findings/Discussion  No significant difference in both groups concerning demographic

characteristics including age, sex, marital status, occupation, level of
education, types of surgery and the narcotics and tranquilizers they took after
surgery.
 Chi-square test showed the incidence of delirium on the morning of the
INTEGRATIVE REVIEW 14

second postoperative day as 11.76% and 23.53% in study and control groups
respectively.
 The incidence was 8.83% in study and 26.58% in control group in the
morning of the third postoperative day. Chi-square test also showed a
significant difference in comparison of relative frequency of delirium in the
first, second and third time between study and control groups.
 Results showed that appropriate relationship of the family with the patient,
through structured and regular visits to the patients after cardiac surgery,
notably reduced the incidence of delirium in the patients in the study group.
 Can be diminished by 21%.
 Showed that involvement of the family in patients’ situation can bring about
patients’ education, relief, peach and feel of safety and reduce delirium.

Appraisal/Worth to  Non-mediational strategy in the prevention of delirium includes the

practice involvement of patients’ family and their support after the surgery can prevent
delirium and its results complications
INTEGRATIVE REVIEW 15

APA Citation Author  APA citation: Rosa, R. G., Falavigna, M., da Silva, D. B.., Sganzerla, D.,
Qualifications Siqueira Santos, M. M., Kochhann, R., … Teixeira, C. (2019). Effect of
flexible family visitation on delirium among patients in the intensive care
unit. Journal of the American Medical Association, 322(3), 216–228.
Retrieved from: doi: 10.1001/jama.2019.8766
 Rosa, MD, PhD – s a Critical Care Physician and Researcher at Hospital
Moinhos de Vento, Porto Alegre, Brazil. He is also an Executive Committee
member of Brazilian Research in Intensive Care Network (BRICNet).
Background/Problem  Flexible visitation policy for family members in intensive care units (ICUs)
Statement has been recommended by professional society guidelines as an important
step toward patient- and family-centered centered care. Flexible ICU visiting
hours may contribute to delirium prevention and stress reduction among
patient as well as improvement in family satisfaction.
 Many ICU’s still have restricted visitation models and are motivated by many
negative factors.

Conceptual/theoretica  None
l Framework

Design/  Cluster-crossover randomized clinical trial involving patients, family

Method/Philosophical members, and clinicians
Underpinnings

Sample/  3,482 participants, 36 adult ICUs (medical-surgical adult ICUs with 6 or more
Setting/Ethical beds and restricted visiting hours at public and private nonprofit hospitals in
Considerations Brazil
 Patients 18 years or older admitted to participating ICUs
 Mixed consent process, consent was waived in 33 of the ICUs based on the
nature of the proposed interventions. In 3 ICUs written consent was deemed
necessary and was obtained from patient or their proxies (autonomy was not
INTEGRATIVE REVIEW 16

ensured)
 Institutional review board of all participating centers approved the study
Major Variables  Incidence of delirium during ICU stay
Studied (and their  Flexible visitation
definition), if  Restricted visitation
appropriate  Prevalence of burnout
 Family self-perception of involvement in patient care
Measurement  ICUs were consecutively randomized in a 1:1 ratio using computer-generated
Tool/Data Collection randomization with random block sizes of 2,4 and 6 and stratified by number
Method of ICU beds. A statistician blinded to cluster identity performed
randomization.
 The flexible visitation model included both flexibility of ICU visiting hours
and family education. One or 2 close family members were allowed to visit
the patient for up to 12 hours per day.; only 1 relation was enrolled in the
study.
 In the restricted visitation model, visitors were allowed as before
randomization, according to local hours. Visitors were not required to attend
educational meetings.
 Exclusion criteria were coma (RASS score less or equal 4), brain death,
palliative care, inability to communicate and other criterion.
 For each patient 1 relative was enrolled; day shift physicians, nurses, nurse
technicians and physiotherapists were eligible to participate
Data Analysis  Data from participants with a recorded outcome were analyzed according to
randomization group.
 Primary outcome was assessed using generalized estimating equations (GEE)
with adjustment for cluster and period effects and for interaction between
intervention and period.
 Prespecified subgroups were defined according to baseline risk of delirium
assessed by the Prediction of Delirium in ICU patient (PRE-DELIRIC) score
and severity assessed by the Acute Physiology and Chronic Health Evaluation
II (APACHE –II) score and according to reason for ICU admission;
 Prevalence of burnout was analyzed using GEE with adjustment for cluster
INTEGRATIVE REVIEW 17

effect and baseline MBI total scores.

Findings/Discussion  The trail was feasible as reflected by te high adherence of ICUs to

implementation. Although flexible visitation resulted in increased presence of
family member at the bedside and in higher perception of involvement in
multiple strategies aimed to prevent delirium, such as reorientation,
mobilization, and pain control, it was insufficient to prevent delirium.
 This contradicts previous before and after studies

Appraisal/Worth to  Added information on the effect of flexible and restricted visitation hours on
practice the incidence of delirium

APA Citation Author  APA citation: Smithburger, P. L., Korenoski, A. S., Alexander, S. A., &
Qualifications Kane-Gill, S. L. (2017). Perceptions of families of intensive care unit patients
regarding involvement in delirium-prevention activities: A qualitative study.
Critical Care Nurse, 37(6), e1–e9. Retrieved from: doi: 10.4037/ccn2017485
 Smithburger (2017) – PharmD, MS, BCPS, BCCCP; Associate professor of
Pharmacy and Therapeutics at the University of Pittsburgh School of
Pharmacy, Pennsylvania. She practices in the medical intensive care unit at
UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania.
Background/Problem  Often, nonpharmacologic delirium-prevention strategies are used in the
Statement intensive care unit by bedside nurses. With 80% of intensive care unit patients
becoming delirious, and lacking treatment options, prevention is key. This
calls for innovative prevention strategies such as involving the family.
Conceptual/theoretica  Grounded theory
l Framework

Design/  Qualitative – 24 bed medical ICU; families participated in the initial family
Method/Philosophical delirium survey investigation. The primary investigator (P.L.S.) conducted the
Underpinnings in-depth, semi-structured interviews and obtained verbal consent before the
INTEGRATIVE REVIEW 18

interview began. Each interview lasted approximately 10-15 minutes and was
audio recorded and then transcribed.
Sample/  62 family member that completed the family opinion survey; medical ICU;
Setting/Ethical  approved by the University of Pittsburgh Institutional Review Board
Considerations  families provided consent and telephone number to be recontacted for
telephone interview
Major Variables  Perceptions of families of intensive Care Unit patients regarding involvement
Studied (and their in delirium-prevention activities
definition), if
appropriate

Measurement  Two investigators independently read and the coded the transcripts. A coding
Tool/Data Collection frameworks was used and basic themes emerges. Phrases and sentences
Method capture from the interview were assigned codes; accompanying specific
description defined the codes.
 Coding was conducted using the qualitative research management software
NVivo;
 Demographic data were obtained from the initially conducted paper surveys
and summarized using descriptive statistics.
Data Analysis  Of the 62 family members who completed the family opinion survey, 45
indicated they would be willing to be contacted for a telephone interview. Of
the 45, 10 interview were chosen by purposeful sampling, were conducted
before thematic saturation occurred.
 Thematic saturation was determined independently by the 2 coders. The
median age of those completing the interviews was 54.5 years and 80% were
female. Most interviewees were either the patients spouse or child.

Findings/Discussion  Three theme emerged: consistent family presence and participation in care,
improving ease of interaction between family and patient and delirium
education for families.
 Without any education or training from health care providers, family
members have illustrated their desire to communicate with their loved one
INTEGRATIVE REVIEW 19

and their willingness to bring in items, such as pens, paper and whiteboards,
to assist with communications. The desire to be involved in care that was
identified was not different than other reports of family involvement in the
ICU.
 97% of family members reported willingness to assist with patient-care
activities, only a minority of family members (13.8%) started an activity
without being encouraged by a health care provider.
 Clear communication and expectations on day 1 would be beneficial
 The unit in which this investigation took place has an open visitation policy.
That ability, increased accessibility.
Appraisal/Worth to  Limitation of study being conducted at academic medical center, and patient
practice have multiple comorbidities; may differ from community hospital setting.
Level of education around this area would be a big factor for health literacy as
well.
 Contribute to research on family involvement in prevention of ICU delirium
but from a qualitative and family’s perspective

APA Citation Author  APA citation: Rosa, R. G., Tonietto, T. F., da Silva, D. B., Gutierres, F. A.,
Qualifications Ascoli, A. M., Madeira, L. C., … Teixeira, C. (2017). Effectiveness and
safety of an extended ICU visitation model for delirium prevention. Critical
Care Medicine, 45(10), 1660–1667. Retrieved from: doi:
10.1097/ccm.0000000000002588
 Rosa (2017) – MD, MSc, PhD; Intensivist in the department of Intensive
Care, Hospital Moinhos de Vento, Porto Alegre, Brazil
Background/Problem  Delirium is a form of acute brain dysfunction that occurs in the critically ill. It
Statement can present as a major challenge for critical care professionals as it is
associated with increased mortality, long ICU and hospital stay, higher costs
of care, and increase risk of long-term cognitive impairment. It is essential to
identify strategies that can help reduce the risk and burden of delirium in ICU
patients and is the key to improve outcomes.
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Conceptual/theoretica  The aim of the study is to compare the cumulative incidence of delirium
l Framework among critically ill patients admitted to a single medical-surgical ICU in the
presence of a restricted visitation model (RVM) or an extended visitation
model (EVM)
Design/  Prospective before and after study
Method/Philosophical
Underpinnings

Sample/  31-bed tertiary medical-surgical ICU, above the age or equal to 18 years old
Setting/Ethical with expected length of stay greater than or equal to 24 hours
Considerations  Study was in three consecutive periods
 Study was approved the Research Ethics Committee at Hospital Moinhos de
Vento
 Informed consent was waived due to standard of care encompassing both
study intervention; provided information oral and written to participants or
surrogates
Major Variables  Restricted Visitation Model – two or fewer family visitor per patient at a time
Studied (and their allowed up to 4.5 hr/d divided into three periods (9:00 to 11:00 AM, 4:00 to
definition), if 5:30 PM and 9:00 to 10:00 PM)
appropriate  Extended Visitation Model – two or few at a time allowed for up to 12 hr/d
(9:00 AM to 9:00 PM); EVM families were allowed to participated on
bedside multidisciplinary rounds
 Incidence of delirium among ICU patients
Measurement  Diagnosis of delirium was made using the CAM-ICU assessment toll every
Tool/Data Collection 12 hours shift in patients with RASS greater than or equal to -3 by trained
Method nurses.
 Delirium was defined as being present for at least on 12-hour shift during ICU
stay
Data Analysis  Fisher exact, chi-squared, Wilcoxon rank-sum and Student t-test were applied
 Significance level of 0.05 was adopted for all comparisons.

Findings/Discussion  Primary outcome: (9.6%) during EVM and (20.5%) in RVM.

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 An extended visitation policy was associated with lower cumulative incidence

of delirium.
 Promotes family engagement and improve communication between patients
and ICU staff and provide better understanding of patient risk factors for
delirium.
 Patient stress and anxiety may be reduced

Appraisal/Worth to  Single center study (generalization), susceptible to biases (Hawthorne effect),
practice no control of important risk factors for delirium (sedation and exposure to
opioids and benzodiazepines), did not evaluate impact on ICU staff
 Use of strategies to avoid contamination bias, follow up by independent team,
measurement of variables and outcomes according to previously defined
objective criteria

APA Citation Author  APA citation: Martinez, F. T., Tobar, C., Beddings, C. I., Vallejo, G., &
Qualifications Fuentes, P. (2012). Preventing delirium in an acute hospital using a non-
pharmacological intervention. Age and Ageing, 41(5), 629–634. Retrieved
from: doi: 10.1093/ageing/afs060
 Martinez (2012) – Professor in the school of Medicine, University of
Valparaiso in Chile
Background/Problem  Delirium is associated with short and long-term complications where
Statement prevention can play a key part in reducing the impact it has on patients. The
study aims to assess the efficacy of multicomponent intervention in delirium
prevention

Conceptual/theoretica  None
l Framework

Design/  Prophylactic environmental management of in-hospital delirium (PEMID); a

Method/Philosophical single-blind randomized controlled clinical trial designed to assess the
Underpinnings efficacy of multicomponent system in contrast to standard management, to
prevent delirium
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Sample/  Elderly patients in the internal medicine war of the Hospital Naval Almirante
Setting/Ethical Nef
Considerations  Total of 287 patients who were at an intermediate or high risk of developing
delirium were randomized to receive non-pharmacological intervention by
family members or standard management.
 Full informed consent was gather from all patients or their representatives
prior to the randomization
 Exclusion and inclusion criteria outline in article
 The ethics committee of Naval Hospital Almirante Nef approved the study
Major Variables  Incidence of delirium
Studied (and their  Control group (no intervention)
definition), if  Group that received non-pharmacological intervention by family
appropriate

Measurement  Out of the 287 patients who finally underwent the randomization process, 144
Tool/Data Collection were enrolled in the treatment group and 143 in the control group.
Method  Data collection consisted of brief interviews and being visited on a daily basis
to assess the presence of delirium with the confusion assessment method tool.

Data Analysis  Data was analyzed with intention-to treat basis.

 The Fisher’s exact test was used and quantitative variables were compared
using the Mann-Whitney or Student’s t-test. The variances were tested with
Kaplan-Meier, Kolmogorov-Smirnov and Levene tests.
 The analysis was preformed by a statistician who was unaware of the study
being conducted

Findings/Discussion  Incidence of delirium occurred in 5.6% of patients in the intervention group

and 13.3% in the control group

Appraisal/Worth to  Applicable study that uses non-pharmacological intervention; older adult

practice population and studied the risks of developing