Virtual Engagement of Families in the Intensive Care Unit During COVID-19: A Descriptive Survey of Family Members of Patients and Health Care Workers

Introduction

Coronavirus disease (COVID-19) has globally impacted daily lives and disrupted usual processes of care in hospitals. Digital technologies were rapidly deployed across health care services to shift many processes and care models to virtual platforms,^1–4 to reduce the chance of nosocomial acquisition of COVID-19 by health care workers and patients. Disruptions to usual processes of care, including restricted or barred family visitation, have been distinctly evident in the intensive care unit (ICU).

Patients admitted to ICU are critically ill and family engagement is essential, though impeded by factors unique to the ICU environment including the patient’s inability to communicate, lack of space in open plan, multi-bedded rooms, restricted visiting hours, and perceived workflow interruption.^5,6 Family members of critically ill patients need honest, accurate, and current information that can be shared regularly.^6–8 Face-to-face meetings with open dialogue are a strategy employed to assist in meeting communication needs.^9,10 COVID-19 presents unique challenges, as face-to-face visits are restricted or barred due to local and governmental regulations.¹¹

COVID-19 poses unprecedented challenges to the delivery of health care.¹² Given visitor restrictions, technology must be utilized to enable virtual visits and information sharing through virtual family meetings in the ICU; the forefront of care delivery in the pandemic. Currently, there is an emerging body of evidence surrounding the application of technology for virtual visits and virtual meetings in the ICU environment.^13–15

This study aimed to explore the experiences and satisfaction of both family members of critically ill patients in the ICU and health care workers caring for these patients utilizing technology for virtual visits and virtual family meetings.

Methods

The study used a pragmatic post-test survey design. The study was conducted for 10 months from October 2020 to August 2021, inclusive of a 4-week break in recruitment, in the 36-bed ICU of a speciality metropolitan health care facility in Australia. The ICU admits ∼2,500 patients per year. Patients admitted are high acuity with an Acute Physiology and Chronic Health Evaluation II mean score of 18 and mean length of ICU stay of 3.6 days. Medical diagnoses include acute neurological disorders, respiratory diseases, renal dysfunction, burns, sepsis, and multi-trauma injuries. The ICU is staffed with ∼16 medical staff specialists (intensivists), 32 senior and junior medical registrars, and 204 registered nurses who deliver and are responsible for, complete patient care.

Participants, all over the age of 18 years, were a convenience sample of family members and health care workers who participated in virtual visits or virtual family meetings. Family members were broadly defined to include all individuals identified to be mutually involved in the care of the critically ill patient irrespective of the biological, or legal relationship. Health care workers were allied health, medical, and nursing staff directly involved in patient care.

The study instruments comprised three surveys: 2 for family members and 1 for health care workers. The first survey assessed the technology available to family members and addressed the type and features of the device intended to be used, the available internet access, data usage capacity, available software and e-mail, and a self-assessment of experience in the use of applications (apps) and support requirements. The second survey comprised questions related to family member characteristics, the type of virtual engagement (visit or meeting), app used, need for assistance, usefulness of the guides, benefit of the visit, and the benefit and continuance of the virtual visit or meeting. The health care workers survey comprised questions related to demography, the technology used, assistance (if required), the usefulness of the guides, the type of virtual engagement (visit or meeting), a scale to rank whether the virtual visits reduced anxiety about the cessation of traditional visits and the benefit and continuance of the virtual visit or meeting.

The intervention was virtual visits and/or virtual family meetings defined as an internet-based videoconference episode of interaction between family members, patients, and health care workers. The virtual visit and/or virtual family meeting, used applications (apps) on dedicated Queensland Health iPads and the family member’s device, with a choice between Facetime, WhatsApp, Google Duo, or Microsoft Teams. The social worker or local technological champion, a resource person (commonly a clinician who received additional, in-depth training surrounding the use of technology for virtual visits and virtual meetings), assisted in the intervention. The family member first completed a technological assessment (Supplemental File S1) and decided upon the app to be utilized. Second, the social worker or technological champion e-mailed instructions to the family member relating to their app (Supplemental File S2). Third, a pre-test of technological devices was conducted, to confirm interface and logistical arrangements such as camera placement, sound quality, and noise interferences.

Health care workers involved in virtual visits and virtual family meetings were provided with face-to-face education from local technological champions for virtual visits and virtual meetings. In addition, local policy compliant guides are available to all staff (Supplemental File S3).

To organize a virtual visit, the health care worker called a patient’s family member on the chosen app while at the patient’s bedside. The nurse positioned the camera, adjusted the volume, and answered family members’ questions within their scope of practice. Virtual visits were offered for 20 min once each day per patient.

The ICU medical staff, the health care worker caring for the patient, social worker, and other appropriate medical teams gathered in a quiet meeting room to conduct virtual family meetings. Throughout the meeting, the ICU medical staff specialist provided a detailed explanation of the patient’s condition including the presenting problem, current management, and patient progress to date. The family could direct questions of any of the participating health care workers. Duration and frequency of family meetings were at the discretion of the ICU medical staff and social worker, or as requested by the family member, and varied based on patient acuity, interventions, and potential morbidity and mortality.

Following the conduct of a virtual visit or meeting an invitation to participate in the electronic survey was sent via e-mail or phone text message to eligible family members (Supplemental File S4) and health care workers (Supplemental File S5). An electronic screening log, detailing the number and type of contact approaches sent to family members and health care workers was kept on a secure password protected file and network. Completion and submission of the survey implied consent to participate. However, once the survey was submitted, responses could not be withdrawn.

Survey data were collected using Microsoft Forms, which is a web-based application that is part of the Office 365 environment, and associated with a private Microsoft Teams site. Access to the site was limited to the research data collection team. Data were entered into IBM SPSS Statistics (Version 24.0; IBM Corp., Armonk, NY). Descriptive statistics were analyzed using counts and frequencies or means and standard deviations as appropriate to the data type. Family members’ and health care workers’ survey responses were not matched to the episode of virtual visit or meeting and therefore responses between groups varied.

Results

During the study period a total of 132 virtual family visits were conducted, with 38 of these repeat visits, and 11 were for patients receiving palliative or end of life care. During the study period, a total of 401 family meetings were conducted. Health care workers reported that 22 were virtual meetings and family members reported on 31 virtual meetings. Both groups reported that a minority of visits or meetings were audio only (health care workers 1.9%; family members 4.3%). We received survey responses from 106 health care workers and 69 family members; however, all health care workers and family members who participated in virtual visits or meetings were invited to participate so that one visit or meeting occasion could have multiple participant responses.

HEALTH CARE WORKERS SURVEY

Health care worker respondents were mostly nurses (92.5%, n = 98). Facetime was the most reported used app among health care workers (82.1%, n = 87). Other apps were rarely used. Most health care workers had used this technology before (85% n = 90) and almost all virtual communications, meeting or visits, by health care workers were audio and visual (98.1% n = 104). Health care workers’ prior experience with the virtual technology resulted in only 18.9% (n = 20) requiring assistance with meeting set up. Set up assistance was provided mostly by the social workers or information technology support (Table 1).

The virtual communication purpose described by the health care workers was primarily a virtual visit (79.2%, n = 84). Sometimes the purpose was for a virtual family meeting (12.3%, n = 13), occasionally the meeting purpose was both a visit and meeting (8.5%, n = 9). Patients were conscious for the meeting about 50% of the time (53.8%, n = 57). The virtual meeting assisted with health care workers’ anxiety resulting from the restrictions on traditional face-to-face meetings. On a scale of 0–10 with zero recorded as strongly disagree and 10 as strongly agree, health care workers recorded a mean of 6.9 (standard deviation [SD] 2.3), indicating that they agreed that the virtual meeting reduced their anxiety. Health care workers who participated in a virtual family meeting (n = 22) were asked whether they were able to effectively read the non-verbal cues of the family members. Using the same scale, the health care workers stated they were in moderate agreement (mean of 6.8, SD 2.4).

FAMILY MEMBERS SURVEY

Family member respondents were more likely to be female (63.8%, n = 44) but age was spread with slightly more respondents aged 35–64 years. Most respondents were close family (43.5%, n = 30), a quarter were spouses (29.0%, n = 20), and a quarter were extended family (23.2%, n = 16). Patients of these family members were conscious 71.0% of the time (n = 49) during the virtual communications. Of the participating family members 65.2% (n = 45) resided beyond 50 km of the hospital (Table 2).

Family members used a wider variety of apps for the virtual communication compared to the health care workers. Facetime again was the most used app (62.3%, n = 43) among family members, however, other apps such as WhatsApp, Zoom, and Facebook were also used during virtual communications. The majority (90%) of family members reported having used these apps before. The virtual communications were both audio and visual (91.3%, n = 63). Few family members needed assistance (7.2%, n = 5) and this was provided by a family member or nurse. A third found the “how-to-guides” helpful. The purpose of the communication was for a family meeting (40.6% n = 28) or included a virtual visit with a bedside update (36.2%, n = 25), only 18.8% (n = 13) of communications were for a virtual visit only.

Family members (n = 44,) were asked if the virtual visit was beneficial. On a scale of 0–10 with zero recorded as strongly disagree and 10 as strongly agree, family members recorded strong agreement (mean 9.4, SD 1.2) that the virtual visit was beneficial. Furthermore, 95.5% (n = 42/44) of family members would participate in another virtual visit with their family members and 98.6% (n = 68/69) agreed that virtual visits should continue once the restrictions had lifted. Most family members felt included in the virtual family meeting (96.4%, n = 54/56) and felt the technology allowed them to voice their questions (94.6%, n = 53/56).

Discussion

Virtual visits and meetings were reported as a useful tool by both family members and health care workers. During an infectious disease pandemic when family visits are restricted or banned, technology can be used to enhance family member engagement and connectedness with the patient in ICU and to provide communication channels. Family members of patients admitted to the ICU experience high levels of anxiety and uncertainty.¹⁶ Our results are congruent with the findings of previous work,^13,14 where the use of apps, has been shown to improve the flow of communication between family members and health care workers. Further, our study showed that virtual communication was positively received by all participants.

The global pandemic has evidenced swift recognition and adoption of the use of virtual platforms for clinical purposes. Virtual family meetings are now frequently conducted and visits are facilitated by apps such as Facetime and WhatsApp allowing family members a sense of “presence” in the ICU.¹⁷ However, there are challenges associated with this approach such as privacy concerns, internet security, and network connection.¹⁸

In this study, we addressed several technical considerations such as patient confidentiality, staff privacy, and unmonitored accounts. Microsoft Teams was the preferred platform for conducting virtual meetings. To facilitate virtual meetings while protecting the privacy of staff, federated generic accounts were established. These generic accounts had access to the Microsoft Office 365 suite, enabled staff to organize a Microsoft Teams meeting and notify family members of this virtual appointment via e-mail.

Staff responsible for organizing a virtual appointment, were instructed to review meeting options. There were 2 options pertaining to the roles of participants who attended. Typically, staff were the presenter and had the ability to control the meeting (i.e., start or end the meeting, accept participants from the lobby, mute participants). Family members attended as attendees. Their capabilities in the meeting were limited. Attendees were not able to record the meeting.

The purpose of e-mailing family members from a generic account was to provide them with details of an upcoming virtual meeting while maintaining staff privacy. The generic account was not set up to receive communication from family members. An automatic reply was set up on each generic account, informing family members that it was an unmonitored e-mail account with details on how to get in contact with ICU. In relation to the use of mobile phones as a platform for the purposes of Facetime and Google Duo, it was also recognized that family members could possibly try to contact these devices. Subsequently, call forward was set up to ensure the call was transferred to the hospital switch board.

LIMITATIONS

Our study was limited to a single center and thus may lack generalizability. The subjects surveyed were a cross section of volunteers among those who participated in the intervention. We acknowledge we missed input from those who chose not to utilize this technology or complete the survey and that not all episodes of virtual visits or meetings were captured. Also, we acknowledge the inclusion of repeat visits/repeat subject surveys in the data collection that may have biased the responses. Further research is warranted to address the challenges health care workers face in providing timely virtual communication to family members of patients in the ICU. We did not examine the frequency of virtual communication episodes that family members feel would be beneficial nor did we explore the impact of virtual visits and meetings on health care workers’ workload. These are areas for future consideration and research.

Conclusion

Our study highlights that the use of virtual technology is effective in delivering a communication platform for family members of patients in the ICU to either visit the patient or conduct meetings with health care workers.

Disclosure Statement

No competing financial interests exist.

Funding Information

This study was funded by a grant from the Royal Brisbane and Women’s hospital foundation.

Supplementary Material

Supplementary File S1

Supplementary File S2

Supplementary File S3

Supplementary File S4

Supplementary File S5