Harnessing Active Relationships within VA ICUs to Engage Surrogates and Care Teams (HARVEST)

Veterans Health Administration, Decatur PA

Investigators

Abstract

Background: Family-centered ICU care—an evidence-based approach that prioritizes family members’ presence in the ICU, incorporates them as care partners, and responds to their values and needs—improves outcomes for patients, families, and clinicians. The Society of Critical Care Medicine recommends the routine use of practices within four key family-centered care domains: 1) unrestricted family presence and participation in care; 2) daily communication between care teams and families; 3) regular use of educational/bereavement materials; and 4) integration of interdisciplinary personnel (e.g., social workers, chaplains) into the care team. However, family-centered ICU care remains underutilized across U.S. hospitals. There is an urgent need to ensure family-centered ICU care is being delivered as standard of care for Veterans and their families. Significance: The objective of this study is to ensure VA ICUs consistently deliver family-centered care. The central hypothesis is that current practices vary widely and are not tailored to the specific needs of Veterans or their families. This proposal directly aligns with VA’s Whole Health Initiative and Strategic Priorities for Research by prioritizing what matters to Veterans and their families and by informing efforts to provide more equitable care. It will also increase the real-world impact of VA research by leading to a future implementation trial that tests strategies to ensure family-centered ICU care is delivered consistently across VA. Innovation & Impact: This proposal will be the first national study to evaluate the delivery of family-centered care within VA ICUs. Additionally, its mixed methods approach will probe the intersection between care models unique to VA (e.g., telecritical care), important subgroups of Veterans (racial/ethnic/rural minorities), and the delivery of family-centered care. This study will inform efforts to tailor family-centered care to the unique needs of Veterans and their families and within the context of VA’s organizational structure and available resources. Specific Aims: 1) To characterize family-centered ICU care practices across VA and evaluate hospital-level factors associated with the delivery of specific practices; 2) To evaluate enablers and barriers to family- centered ICU care practices through the perspectives of Veterans, their families, and ICU clinicians; 3) To develop a strategic plan that promotes implementation of family-centered ICU care practices across VA. Methodology: Aim 1 will survey ICU nurse managers from VA hospitals with ICUs nationally (n~115) to characterize delivery of family-centered care practices and then examine the association between hospital- level characteristics and the use of specific family-centered ICU care practices. Aim 2 will sample 6-8 VA hospitals based on geographic region, rurality, and Veteran demographics. Site visits with observations and semi-structured interviews of up to 72 key stakeholders, including Veterans, their families, and ICU staff, will be conducted. Aim 3 will convene a modified Delphi panel of ~20 subjects, including Veterans, families, clinicians, and administrators. The study team will then develop a strategic plan to promote the implementation of family- centered care practices that are tailored to Veterans and their families within the context of VA. Next Steps/Implementation: The strategic plan will be disseminated using a multi-faceted approach, building on the study team’s relationships with multiple government offices to reach VA ICUs across the U.S. As a next step, the study team anticipates testing these implementation strategies in a type III hybrid effectiveness- implementation trial, which will leverage the network of VA ICUs that will be created as part of this study.