When Brigham and Women's Hospital in Boston opens its new cardiovascular wing in May, all 136 rooms - even those for intensive-care patients - will include a family sleeping area.
Among the amenities: a pull-out bed with bed linens and a flat-screen television.
The rooms will be as big as 350 square feet - about double the size of the hospital's current rooms - and patients will be able to designate a relative or friend to stay with them each night, basically living alongside them in the room.
Doctors and nurses will encourage family members to help provide basic care, such as bathing and changing bandages, and allow designated individuals to remain in the room for most procedures, including removal of chest tubes, insertion of intravenous lines, and even resuscitations.
"Pediatric hospitals have embraced this for years; the family is not thought of as a visitor," said James Conway of the Institute for Healthcare Improvement, a nonprofit research organization in Cambridge that has pushed the opening of adult ICUs to families.
Brigham officials say this is the only cardiovascular center in Boston designed to include a family member in the patient's room.
The Brigham is one of a growing number of US hospitals experimenting with open access or nearly open access for families of adult ICU patients - an idea that has met with opposition from staff at every institution that has tried it, at least initially.
Many Brigham nurses also were uncomfortable with the concept at first - and some still are - though the hospital already has a relatively liberal visiting policy in the ICUs; exceptions are often made to the official visiting hours of 1 to 9 p.m.
They worried that families with their own demands and questions would distract nurses from caring for patients. Nurses also were concerned about having to clean up after them - or having to tend to fainting or upset family members during graphic or emergency procedures.
"People die in the ICU if you miss something," said nurse Karen St. Martin, who works in the eighth-floor cardiac ICU. "It has to be a controlled environment."
But after St. Martin and other nurses helped develop ground rules spelling out nurses' roles and establishing boundaries for family members, most staffers are now happier about relatives being a near-constant presence.
Some, like Meteriver "Thelma" Kincaid, already spend day and night at the hospital. The 65-year-old Bostonian has been living nearly full-time in the cramped family waiting room on the Brigham's eighth floor since October. Her daughter, Lauren, 23, who is suffering from heart failure, has had four operations since June, the most recent on Oct. 2, to try to repair a leaky artery.
Even without the washing-machine-sized cardiac assist device next to Lauren's bed, there would be little space for Kincaid to sleep in her daughter's ICU room. So each night between 11 and midnight, when most visitors have left the family room, she rolls out a fold-up cot, makes the bed amid the half-full coffee cups and soda cans, and closes the door so she can sleep. Lately, another female visitor she has gotten to know has slept in a cot next to her. But sometimes Kincaid shuts her eyes inches from a complete stranger.
The nurses know Kincaid and allow her generous visiting time with her daughter, but she said "the privacy [of in-room accommodations] would be nice."
Dr. Donald Berwick, president of the influential Institute for Healthcare Improvement, several years ago challenged hospitals to open ICUs to families, to improve the quality of care and the hospital experience for both patients and families. He and other supporters pointed to a few hospitals where patients went home sooner and medical errors dropped after family members were let in to ICUs, partly because they noticed problems like missed medication.
But the idea remains controversial among hospital workers around the country. Internet message boards devoted to healthcare are filled with debate about the subject. On an institute online discussion group, one ICU nurse said open access was a success at her Midwestern hospital, and to keep out family "may cause more pain and suffering to the patient." But another nurse complained, "It is total mayhem," and still another wrote, "You end up spending more time tending to the family members than caring for the patient."
At Geisinger Health System in Danville, Pa., the hospital's initial attempt to open its ICUs 24 hours a day failed. The hospital limited visitors to two at a time and required them to leave during procedures.
"It didn't work when we trialed it," said Angelo Venditti, operations manager and a nurse at Geisinger. "Nurses were afraid to ask families to leave. So they didn't give families a good reason to step out. Families didn't understand and got into debates about why they had to step out."
The hospital rethought its plan. It trained nurses in communication skills, let doctors and nurses decide when families could stay for procedures, and set up a system of lights to signal when relatives could return to the room. Now, open access is working well, Venditti said.
Brigham staff and executives acknowledge that having family members around more often will be an adjustment for all concerned. Loved ones may find they don't get much sleep in an ICU room, given that nurses check patient's vital signs constantly, and some may decide not to stay. In other cases, patients may not desire that much togetherness with their families.
The nurses committee that drafted guidelines for the hospital's new Shapiro Cardiovascular Center sought to strike a balance. The group recommended developing a family handbook that explains the hospital's expectations for relatives staying overnight in a patient room, including that nurses will not make their beds and may ask them to leave for certain procedures. The hospital will train nurses how to communicate with families, and also promised nurses help from social workers and other staff.
Family members, along with the patient, will be briefed on each day's treatment plan, but families won't be present when nurses exchange information about patients during shift changes, a rapid, highly technical conversation.
Now, several nurses said, they feel more comfortable that the change will work.
"Things are shifting," said Matthew Quin, nurse manager of the Brigham's eighth-floor cardiac units. "Families are becoming part of the care team. They're healers too."
