Virtual Communication in the Hospital: Impact on Patients and Surrogates

As the COVID-19 pandemic exploded, hospitals across the globe completely excluded or severely limited family visitors. Thousands of patients have faced life-threatening illness or died without any loved ones at the bedside. Patients with AD were often unable to understand why their family members could not be present, leading to increased agitation. The calming presence that family often provide to hospitalized patients was missing. In addition to the tragedy for patients, family members were forced to address decisions about life-sustaining treatments without being able to see the patient or talk face to face with clinicians. As our knowledge of coronavirus transmission expanded, visitor restrictions have been relaxed in some cases but not eliminated. Urgent interventions are needed to mitigate the harm of these restrictions. While the future is uncertain, COVID-19 cases are rising across the country, suggesting that visitation will continue to be restricted. Additionally, our tertiary referral center often admits patients from across the state, limiting the ability of family members to be at the bedside. Harnessing virtual technologies has the potential to enhance surrogate/clinician communication and decision making during the pandemic and after.

Telehealth has greatly expanded the abilities of patients to see clinicians remotely or for clinician to clinician consultation, but prior to COVID-19 there were few interventions aimed at the family members of hospitalized patients. We feel we are poised to rapidly move along the NIH research pathway given that we are studying our early implementation. At the conclusion of this pilot, we will then conduct an effectiveness trial, followed by an embedded, pragmatic clinical trial.

• VCHIPS (Other): Participants in this group will have the opportunity to receive virtual visits with the patient during the hospital stay, led by a study nurse.

Primary outcomes

• Measure change in ratings of communication quality among study participants using the FICS at baseline, 6-8 weeks after patient discharge, and 6 months after patient discharge [6-8 weeks after discharge, 6 months after discharge]: Communication quality will be measured using the validated Family Inpatient Communication Survey (30 item scale)

Secondary outcomes

• Measure change in participant depression among study participants using the PHQ-8 at baseline, 6-8 weeks after discharge, and 6 months after discharge [Baseline, 6-8 weeks after discharge, 6 months after discharge]: Depression will be measured using the validated Patient Health Questionnaire (8 item)
• Measure change in anxiety among study participants using the GAD-7 at baseline, 6-8 weeks after discharge, and 6 months after discharge [Baseline, 6-8 weeks after discharge, 6 months after discharge]: Anxiety will be measured using the validated Generalized Anxiety Disorder-7
• Measure change in the impact of events among study participants using the IES-R at 6-8 weeks after discharge and 6 months after discharge [6-8 weeks after discharge, 6 months after discharge]: Impact of Events will be measured using the validated Impact of Events Scale
• Measure complicated grief for study participants of patients who died at 6 months after discharge [6 months after death]: Complicated grief will be measured using the validated Inventory of Complicated Grief
• Measure change in participants' ratings of communication quality over time for the duration of the patient's hospital stay [Communication quality will be measured daily during the first week and twice a week thereafter for the duration of the hospital stay, up to 1 year]: Communication quality will be measured from participants responses to texted survey questions (ecological momentary assessment) written by the study team. Participants will respond on a 5 point Likert scale.

Other outcomes

• Measure the change in observable and/or reported level of pain in patients of participants in the intervention group. [Pre/post observations of pain will occur at the time of study intervention, typically within 1 hour.]: Clinical measures will be obtained through direct observation of the patient by study nurses using the PAINAD scale or through patient self-report using the FACES Pain Scale
• Measure the change in observable and/or reported level of distress in patients in the intervention group before and after study intervention [Pre/post observations of distress will occur at the time of study intervention, typically within 1 hour of each other.]: Clinical measures will be obtained by study nurses using the distress thermometer for patients who are able to self-report.
• Measure the change in blood pressure in patients in the intervention group before and after study intervention [Pre/post observations of blood pressure will occur at the time of study intervention, typically within 1 hour of each other.]: The nurse will obtain the patient's blood pressure before and after the intervention
• Measure the change in heart rate in patients in the intervention group before and after study intervention [Pre/post observations of heart rate will occur at the time of study intervention, typically within 1 hour of each other.]: The nurse will obtain the patient's heart rate before and after the intervention
• Measure the change in respiratory rate in patients in the intervention group before and after study intervention [Pre/post observations of respiratory rate will occur at the time of study intervention, typically within 1 hour of each other.]: The nurse will obtain the patient's respiratory rate before and after the intervention

Sex: All, ages: 65 Years to any

Inclusion Criteria:

Patient:

* 65 years or older
* cognitive impairment due to ADRD, delirium, or other causes of cognitive impairment severe enough that they require a surrogate for all medical decisions
* must have a surrogate decision maker based on a previously executed healthcare representative form or based on Indiana statute.

Surrogate:

* English-speaking
* Surrogate does not plan to be at patient's bedside every day
* surrogate is 18 or older

Exclusion Criteria:

Patient:

* Less than 65 years old
* Incarcerated individuals (e.g. prisoners)
* Lack of cognitive impairment
* Terminal wean/ actively dying

Surrogate:

* Less than 18 years old
* Incarcerated individuals (e.g. prisoners)
* non-English speaking
* plans to be at patient's bedside every day
* has a care contract or flagged for security risk
* state-appointed guardians

• Alexia M Torke, MD, Principal investigator, Indiana University

NIH grants: K24AG053794